THE circumstances surrounding the death of a man in the Royal Victoria Hospital have been condemned as “alarming and shocking” by a Belfast coroner.
Laurence Bradley, from Gortinure Road in Maghera, was admitted to the Mid-Ulster Hospital with a broken arm in June 2006 following a road traffic collision, but within days had been transferred to the RVH.
Due to an underlying chest condition and the onset of breathing difficulties, 64-year-old Mr Bradley was admitted straight to the Intensive Care Unit (ICU) at the Royal.
He was assessed by the consultant in charge of ICU and deemed fit for discharge to the orthopaedic (fracture) ward within 24 hours.
However, the care Mr Bradley subsequently received on the orthopaedic ward was described by a private consultant, Dr Geoffrey Todd, as “unbelievable”.
Mr Bradley died on the morning of June 13 — 11 days after the bus he was driving was in collision with a lorry near Castledawson.
In the days immediately prior to his death, Mr Bradley’s hospital monitoring records were incorrectly completed and therefore failed to show the full extent of his deteriorating condition.
The charts were said to have been completed by nursing staff but the coroner, Mr John Leckey, expressed concern that there appeared to be “a lack of a consultant’s input to care”.
Mr Leckey described the lack of intervention as “a situation I find, quite frankly, extremely disturbing”.
Questioning Dr Gavin Lavery, consultant in charge of the ICU, the coroner asked how a critically low blood pressure reading (64 over 50) from 5am on the morning of Mr Bradley’s death could have been ignored.
Mr Leckey said: “This man was dying at five in the morning and nothing was done. For a hospital of the Royal’s standing that must be a matter of shame?”
Dr Lavery replied: “I agree that Mr Bradley should have had significant intervention. There is no doubt that he should have been transferred back to ICU but he wasn’t.”
Commenting on the accuracy of Mr Bradley’s monitoring chart, Dr Lavery said: “I have reviewed the notes on Mr Bradley and found them to be disjointed and discontinuous.” Dr Lavery said new procedures put in place since 2006 have greatly reduced the risk of similar shortcomings in patient monitoring.
One expert doctor giving evidence said the true extent of Mr Bradley’s condition should have been detected and acted upon days before he died.
John Costello, who for 25 years was the head of respiratory medicine at King’s College Hospital in London, said: “He should have been transferred to ICU and mechanically ventilated.”
Referring to the morning of Mr Bradley’s death, Mr Costello said: “The man was dying, that’s what that blood pressure signified. Intervention, even at that point, could have saved his life.”
Also giving evidence, private consultant physician Dr Geoffrey Todd said the “alarm bells should have been ringing” even before the patient’s condition deteriorated to the extent of June 13.
“Someone receiving 100 per cent oxygen in a fracture ward is something I have never come across before and is unbelievable.”
The inquest hearing is expected to conclude today.