A number of failings - including not passing on medical records - led to the death of a pensioner, who went in for a 'routine procedure.'

Alice Dickenson died on May 9, 2014, at William Harvey Hospital, Ashford, after losing four litres of blood.

An inquest in Folkestone on Monday heard the 78-year-old was admitted after difficulty swallowing and weight loss over three months.

Solicitor Rosaline Wong, of Ashton KCJ, who is representing the family, said: “Mrs
Dickenson’s death naturally came as a great shock since she had gone into hospital for what was assumed to be a routine procedure.

So they understandably looked to the inquest for an explanation of how such a tragedy could have occurred.”

The court heard how the resident of Collingwood Walk, Sittingbourne, underwent an endoscopy to exclude cancer,

But the nurse mistook a gastric varix – dilated vein – as a lesion and decided to conduct a biopsy.

The examination caused the vein to start bleeding heavily.

The retired legal executive had previously been treated at Kent and Canterbury Hospital with excessive iron storage in her liver and a blood clotting disorder.

But this information was not passed on to the nurse conducting the endoscopy, something that could have affected the decision to perform the procedure.

Overnight, Mrs Dickenson’s condition deteriorated before she was found collapsed on the floor the following morning.

After being resuscitated, she was transferred to intensive care.

A scan showed the pensioner had suffered a catastrophic injury to the brain from which she was unlikely to recover.

With her family’s consent, further treatment was withdrawn and she died the next day.

Senior coroner Rachel Redman, recorded a narrative verdict and found the nurse endoscopist was not aware of any pre-existing condition when he scoped her.

The inquest heard William Harvey Hospital has made a number of changes following Mrs
Dickenson’s death, including streamlining admission procedures and ensuring nurses obtain past medical history from a patient rather than relying on documentation.

The East Kent Hospitals University NHS Foundation Trust reiterated its condolences to Mrs Dickenson’s family.

A spokesman said: “A full investigation was conducted at the time and the trust has taken a number of actions to prevent this from happening again.

“The coroner recognised that a comprehensive investigation had been undertaken by the trust and that it had actioned the recommendations which had been put in place.”