A DISABLED man who died of pneumonia in Sunderland Royal Hospital missed doses of medication.
It was revealed at an inquest into the death of Carl Winspear, who suffered from cerebral palsy, there were gaps between some doses of antibiotics, due to the timing of drugs rounds at the hospital, and there was no record of another prescribed antibiotic being given at all.
The 28-year-old – who lived in Columbia, Washington, with mum Elaine – died in January after he was admitted to the hospital with a chest infection.
The inquest in Sunderland heard how Carl was prescribed a range of antibiotics by medics, as there were doubts over the cause of the infection.
A doctor from the hospital claimed he was “90 to 95 per cent sure” the missed doses would not have caused Carl’s death.
However, City of Sunderland coroner Derek Winter is now using his powers to write to the hospital and the Secretary of State for Health in light of Carl’s case.
Dr Andrew Berrington told the inquest in Doxford Park that there was a 14-hour delay between doses of one antibiotic and about 20 hours between another, as they were prescribed after the first doses should have been given.
He said: “I do not like giving percentages on chance, but there was 90 to 95 per cent chance that these delays did not affect the outcome.
“Had we identified the cause of this infection it would have been easier to target the antibiotics.”
Dr Berrington added that a new version of the hospital’s electronic prescription system was being introduced and training for new doctors had been improved.
He said: “We have 50 to 100 junior doctor prescribers in the hospital which turn over every year, so we have to get it right each time.
“With the new system, which is being rolled out in the next year, or so I have been told, the nurses will have a much clearer picture of what happens to previous doses.”
But Carl’s aunty Sandra Noble, speaking on behalf of the family, said: “The hospital have badly let Carl down. No one could have known if any of this medication could have made a difference but he was not given a chance.
“Carl could not communicate that he was in pain. We will never know what happened that night and how Carl suffered.”
The family also raised concerns that a Do Not Resuscitate order was placed on Carl’s file by doctors.
Mr Winter added that he decided to make a report under the Coroners’ Rules as he had dealt with two similar cases.
Verdict: natural causes