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Father died on hospital bathroom floor after doctors failed to give him life-saving drugs
Edward McKean, 52, died on bathroom floor at University Hospital CoventryHad undergone surgery to remove a benign brain tumour three weeks earlier
He died of a pulmonary embolism – a blood clot in the pulmonary arteryHad not received vital blood-thinning drugs which could have saved himInquest heard junior doctor missed the drugs off his medication chart'Neglect' contributed to death and doctors missed opportunities to save him
09:40 GMT, 2 April 2013
10:32 GMT, 2 April 2013
Edward McKean, 52, died after doctors failed to notice he was not receiving vital drugs
A father-of-three died on the bathroom floor of a hospital after a junior doctor left life-saving drugs off his medication chart, an inquest has heard.
Medics failed to realise Edward McKean, 52, was not receiving vital blood-thinning drugs for six days after he underwent brain surgery to remove a benign tumour.
Mr McKean did not receive the drugs – designed to reduce the risk of blood clots – because a junior doctor missed them off his treatment chart when she copied it up.
As a result, a clot formed in Mr McKean’s leg, broke free, and blocked an artery, causing a fatal pulmonary embolism – a blood clot in the pulmonary artery – as he walked to the bathroom.
A post-mortem examination found he had already suffered a smaller embolism which could have alerted doctors to their mistake and saved his life.
A coroner ruled that doctors and nurses missed numerous opportunities to spot their mistake and said ‘neglect’ had been a contributing factor to his death.
An inquest at Coventry Magistrates Court on Friday heard that the keen walker’s life could probably have been saved if the mistake had been picked up.
Mr McKean had surgery to correct a rare tumour in his nasal cavity and skull at University Hospital Coventry, in Walsgrave, on April 3 last year.
He initially received the anti-coagulant medication after the opeation but stopped receiving it following the error.
The contracts manager, from Solihull, West Midlands, died as he walked to the bathroom on April 22, almost three weeks after his operation.
Mr McKean’s partner, Susan Rickards, told the inquest she had ‘fought for a year’ to stop the tragedy being ‘swept under the carpet’.
Describing the moment she learned of his death, she told the inquest: ‘The hospital rang me at five in the morning and told me there was an emergency, so I shot up there.
‘I thought if he saw I was calm it would help him to keep calm.
‘I thought he might have broken his arm or leg, but when I got to the ward they told me he was gone.’
Consultant neurosurgeon Hussien El-Maghraby admitted the mistake should have been detected sooner.
He said: ‘What is serious is that it was not picked up for six days.’
Mr El-Maghraby added that when he learned what had happened, he sent an email to the hospital’s chief executive.
A junior doctor at University Hospital Coventry missed vital blood-thinning drugs off Mr McKean's medication chart and as a result he went without them for six days and died of a blood clot in the pulmonary artery
Deputy coroner Louise Hunt asked him: ‘On a scale of one to ten, how serious would you say these collective failings were’
He replied: ‘Very serious, ten out of ten.
‘That’s what made me send an email.’
The inquest heard the hospital had since improved ward rounds and made other changes to minimise the risk of a similar tragedy.
Ruling that neglect had contributed to Mr McKean’s death, Ms Hunt asked the hospital to send her written confirmation that it had implemented measures to prevent similar mistakes occurring again.
Dr Mike Iredale, deputy medical director, apologised to the family for the ‘unimaginable distress and grief’ the hospital had caused them.
He accepted serious mistakes were made and promised the hospital would continue to improve its procedures.