by Josh Pettitt
Friday, February 22, 2013
Staff at the Royal Free Hospital failed to give a retired social worker potentially life-saving drugs before her death, a court heard.
Alma Fraquelli had gone under the knife at the Hampstead hospital after complaining of pain to her back and legs.
Although the operation went smoothly, doctors failed to prescribe drugs to prevent the 85-year-old from suffering a deep vein thrombosis (DVT) as she recovered from surgery.
Staff admitted they later lost part of her treatment plan the night before she died from a blood clot on her lung on May 26 last year.
The trust which runs the hospital launched an inquiry into Mrs Fraquelli’s death. Investigators found there had been errors in her care and the hospital has apologised to the family.
Although the drugs would have reduced the risk of death, there was still a chance Mrs Fraquelli could have died, St Pancras Coroner’s Court was told on Tuesday (February 19).
Dr Adrian Tookman, divisional director of medicine at the Royal Free, said a special hospital committee had reviewed the case and a number of recommendations to improve patient care had been made as a result of the findings.
“During an inquiry into the death it became clear at an early stage that she had not been given the medication she should have been given,” said Dr Tookman.
“Errors can happen. On behalf of the trust we would like to offer our condolences to you (Lorenzo Fraquelli) and your family as we believe an error has been made.”
Consultant neurologist Robert Bradford recommended that Mrs Fraquelli be put on a small dose of heparin to prevent a DVT after her operation on May 21.
But ward staff failed to administer the drug, possibly for up to five days while she was recovering at the hospital in Pond Street.
Mrs Fraquelli, from Hendon Lane in Finchley, was found collapsed in a bathroom on May 26.
Despite attempts to revive her she died a short time later from a pulmonary embolism.
Recording a narrative verdict, interim coroner Dr Shirley Radcliffe said: “It’s of some concern that Mrs Fraquelli was not given the heparin, not simply on her first post-operative day but the following days.”
She added: “The idea of heparin is to reduce that risk. It’s quite clear the risk of her developing an embolism would have been reduced.”
A spokeswoman from the Royal Free said: “We would like to convey our condolences to Alma Fraquelli’s family.
“We very much regret that although there was a clear post-operative plan to give her treatment aimed at reducing her risk of developing a pulmonary embolism, this was not implemented in full.
“We have conducted an investigation and made changes aimed at preventing such errors in future. We informed Mrs Fraquelli’s family of the error.”