Mrs B went into hospital and when her heart rate dropped, the Trust did not take appropriate action. Ward staff did not have details of her regular medication, so her Parkinson's medicine was delayed.
What happened
Mrs B went into hospital with hip and back pain. Her condition got worse; she developed bronchopneumonia and subsequently died.
What we found
Staff failed to carry out a medicines reconciliation process when Mrs B was admitted, which delayed her essential medication for Parkinson's disease.
Staff did not take any action when an ECG showed a significant drop in Mrs B's heart rate just before she had a cardiac arrest.
However, it was unlikely that any intervention could have been made between the ECG and Mrs B's cardiac arrest, and her death was not avoidable.
Putting it right
The Trust apologised to Miss B, Mrs B's daughter, for the delay in giving Mrs B her Parkinson's medication. The Trust also put together action plans to show how it had learnt from its mistakes with regard to medicines reconciliation and its response to a significant low heart rate, so that the mistakes would not happen again.
Mid Essex Hospital Services NHS Trust
Essex
Not applicable
Apology
Recommendation to learn lessons or draw up an action plan