Published: 05:00, 15 May 2022
| Updated: 10:50, 15 May 2022
A widower whose wife died after mistakes were made at a hospital said she wouldn't have want anyone to be blamed for her death.
Kathryn Millard, who was known as Katie, suffered a blood clot after falling down stairs and fracturing her spine.
The 56-year-old from Rainham was admitted to Medway Maritime Hospital after the fall but developed deep vein thrombosis and died three days later on May, 13, 2021 after suffering a cardiac arrest.
An inquest found Mrs Millard should have been given compression stockings and a drug to prevent blood clots but neither of these were given.
Following the inquest into her death, the coroner has written to the Gillingham hospital to raise concerns.
Ian Brownhill, assistant coroner for Mid Kent and Medway, said: "In my opinion there is a risk that future deaths could occur unless action is taken."
But Mrs Millard's husband Peter said: "My wife was such a loving, generous person in her life and so so kind. I don't want her memory to be dishonoured by blame, bitterness or recriminations. Kathryn was not that sort of person and it is not what she would have wanted.
"I know that a few mistakes were made but no one set out to harm Kathryn, the people who looked after her were good people and they tried so hard to save her."
He added: "Although there were mistakes, there is nothing that could definitively be said caused her death."
In a statement to the inquest court, Mr Millard said: "I would like everyone to be assured that I do not attribute blame or bear anyone ill will.
"However, I , and our family would of course, like, where possible, lessons to be learned and procedures and practice improved."
The inquest found at least one doctor indicated that Mrs Millard needed to wear compression stockings but the nursing staff gave evidence that they were not aware of this.
The inquest found gaps in Mrs Millard's medical records, with the direction of the most senior clinician not documented in her notes and not implemented.
The coroner's report said: "In respect of dalteparin [a drug that prevents blood clots], this decision was initially withdrawn due to an identified risk of bleeding and the prospect of surgery.
"When it was determined that there was to be no surgery, the treating consultant indicated that dalteparin should be commenced. That decision was not recorded in Mrs Millard’s medical notes. The dalteparin was not given."
Mrs Millard fell while working as a private tutor, a job she had done and loved for many years. The mum-of-two taught children with special needs who were being home-schooled and before that she had worked as a teacher in special needs schools including Dane Court in Gillingham.
Mr Millard said children in Medway had lost a "gifted and talented tutor who understood their needs".
He added: "She was absolutely born to teach, it was her vocation. Children loved her and she was able to get the best out of them.
"She was working when she had her accident. She didn't know there were stairs behind her and she fell backwards. But then she got back up and tried to carry on teaching, which just epitomises her dedication to her work."
As well as teaching, she ran a parent and toddler group at Rainham Christian Fellowship in Twydall and a friendship group for older members of the church.
Mr Millard said: "We were married for 30 years and I feel lucky to have been married to her. She was the most kind, supportive person. I miss her more than words can ever say."
Mr Millard said the hospital carried out its own investigation following his wife's death and have already made changes. He praised the trust for being "open and honest".
Medway NHS Foundation Trust’s chief executive Dr George Findlay said: “I would like to offer our sincerest apologies to Mrs Millard’s family for their tragic loss.
“The Trust accepts the coroner's findings and we are carefully reviewing the report to ensure we take the necessary action required to address the matters of concern that have been raised.”