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Darent Valley Hospital apologises to family of Koshalaya Sawhney, from Bexleyheath

Errors made by hospital staff caused an 85-year-old grandmother, originally admitted for a hip problem, to die from a massive stroke, an inquest has concluded.

Koshalaya Sawhney, described as “well loved” by her family, passed away at Darent Valley Hospital on January 18 last year.

She had suffered a brain haemorrhage caused when she was given the incorrect amount of medication.

Koshalaya Sawhney
Koshalaya Sawhney

She was originally admitted to hospital after her hip locked, leaving her unable to get out of her armchair.

On arrival at hospital she was found to have an infection which led doctors to prescribe her new medication alongside her regular doses of anticoagulant Warfarin.

She had previously been diagnosed with atrial fibrillation which put her at risk of having a stroke.

It was the failure of healthcare staff to monitor these properly which caused Mrs Sawhney, of Bowness Road, Bexleyheath, to suffer a fatal brain haemorrhage, the coroner ruled today.

Her daughter Viniti Seabrooke alongside husband Steve Seabrooke had alleged that the negligence displayed by Darent Valley Hospital amounted to an unlawful killing.

However, coroner Roger Hatch told the court that while it was clear that the hospital’s failures caused the death, it did not meet the required level of proof to warrant such a conclusion.

Darent Valley Hospital
Darent Valley Hospital

Speaking at the coroner’s court in Gravesend Old Town Hall, he said: “After she had seized up ... there were problems following in respect of her medication and particularly the monitoring of her levels in respect of the Warfarin. They were not monitored as they should have been.

“I am confident that [the death] was entirely due to the failures of the Trust and poor care at the hospital.

“The family suggest that I should conclude the death as being unlawful. This does not reach the necessary criminal standards to justify such a conclusion in law. There is no evidence of criminality.”

Mr Hatch added that he would be making a report on the case to avoid similar failures happening again.

Koshalaya Sawhney
Koshalaya Sawhney

Susan Acott, chief executive of Dartford and Gravesham NHS Trust which manages the hospital, admitted there were numerous failings in this case.

In a written statement read out in court, she said: “I acknowledge that there were a large number of failures in the treatment of Mrs Sawhney while she was a patient at the hospital.

“I am very sorry and offer a sincere apology on behalf of the Trust for the mismanagement of the test results.”

She said she accepted the mismanagement had caused grief for the family.

Speaking after the inquest, daughter Mrs Seabrooke said: “The coroner clearly saw that the hospital had failed to take proper care of her.

The inquest was being heard at Gravesend Old Town Hall
The inquest was being heard at Gravesend Old Town Hall

“The fact that he at least recognises that gives us some closure.

“There are no winners in this. This is about saving others from going through the same thing at a hospital that is so badly run.

“We are happy that the coroner is writing this report into how bad care was at the hospital.”

A statement issued by Darent Valley Hospital afterwards said: “We offer our sincere condolences and unreserved apologies to the family and friends of Mrs Koshalaya Sawhney.

“I am confident that [the death] was entirely due to the failures of the Trust and poor care at the hospital" - Coroner Roger Hatch

“This was an extremely sad incident and one that resulted in a thorough review of Mrs Sawhney’s care whilst she was with us.

“We have done much to tighten our procedures and improve the way that patients on Warfarin are monitored and managed at this hospital.

“A new Trust wide anticoagulant policy has been implemented and the standard operating procedures in pathology have been amended and updated.

“The nursing documentation has also been reviewed and updated and medical handovers are now recorded electronically for accurate, fast and easy reference.

“We completely understand the family’s distress and anger at losing their loved one and fully accept the coroner’s findings.”

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