A PATIENT died due to hospital staff failing to correctly follow dialysis procedures.

An inquest in Bolton into the death of skilled joiner Jason Farrington concluded that there were delays and missed opportunities for him to receive the treatment he needed at the Salford Royal Hospital.

Assistant Coroner Rachel Syed heard how Jason Farrington, who was suffering from a number of health problems including kidney failure, had been responding well to treatment on the specialist H3 renal ward at the hospital.

In preparation for him returning to his St Gregory’s Close, Farnworth, home, on August 6 last year he was moved to the Pendleton Suite at the hospital.

But during the transfer procedure between wards only verbal instructions were given to the Pendleton ward’s staff, who were not specialists in carrying out dialysis.

Mr Farrington, a 51-year-old single man, was being treated using peritoneal dialysis where sterile solution is run through a tube into the abdominal cavity and out again, flushing out waste products which failing kidneys cannot deal with.

The inquest heard that concerns should be raised if less fluid comes out than goes in and patients need daily weight monitoring to ensure their bodies are not retaining liquid.

But Salford Royal Hospital’s consultant physician Dr David Lewis admitted to the inquest that, while in the Pendleton Suite, Mr Farrington had not been weighed until August 10.

“If that had been evident to nursing and medical teams then there would have been opportunities to change the treatment,” said Dr Lewis. “A significant weight gain should trigger alarm.”

It was found that Mr Farrington’s weight had increased by 8kg in six days, suggesting he had retained eight litres of fluid.

Mr Farrington was moved back to the renal ward on August 11 but died the following day. The coroner ruled that he died of cardio respiratory failure as a result of fluid overload, end stage kidney failure, peritoneal dialysis and heart failure .

“The whole family believed he never should have been moved from the renal unit in the first place, Mr Farrington’s brother, Gary Farrington, said.

Dr Lewis told the inquest that although Mr Farrington was very ill with heart disease as well as kidney failure and likely to live for months rather than years, his death could have been avoided at that time.

Miss Syed asked him: “On the balance of probability, is it more likely than not that, had Jason’s weight been monitored properly over the period from the 4th to the 10th of August, would he have survived?”

Dr Lewis paused before replying: “Yes.”

Tracey Murphy, assistant director of nursing for the renal division at the hospital told Miss Syed that, since Mr Farrington’s death, procedures have been put in place to ensure staff are properly trained in providing dialysis and there are formal written handovers when patients are transferred to other wards, with follow up checks to ensure patients are continuing to get the correct treatment.

In giving her conclusions Miss Syed said that Article 2 of the European Convention on Human Rights, which states that a person has a right to life, was engaged in Mr Farrington’s case.

In inquests Article 2 is engaged when the state may have played a part in a person’s death and Miss Syed told the court that there were “systemic, procedural failings to protect and preserve Jason’s life.”

In a narrative conclusion she recorded: “The deceased died as the result of a delay in monitoring his fluid overload and receiving necessary medical treatment for this condition.”

Miss Syed stressed: “There were two key missed opportunities in Jason’s case. Firstly, there wasn’t a formalised handover and that handover should have consisted of the nurses being aware of their duties to undertake daily weight monitoring. It didn’t take place.

But she added: “I am satisfied that the Trust have taken necessary action to prevent future deaths occurring.”

Addressing Mr Farrington’s family, Miss Syed said: “I hope that now the inquest has been concluded that you can start to really focus on all those wonderful memories that you had with your brother. He sounded like a truly likeable man and I am very sorry you have lost him under these circumstances.”

Following the inquest Mr Farrington’s family declined to comment.

Paul Downes, Director of Patient Safety and Professional Standards at the Northern Care Alliance NHS group which runs Salford Royal, said: “We would like to pass on our condolences to the family of Mr Farrington at this difficult time.

“The circumstances leading up to Mr Farrington’s untimely death have been investigated by Salford Royal. Lessons have been learnt and improvements have been made, particularly regarding the communications between wards to ensure that actions are undertaken to monitor, identify and treat fluid overload quickly. 

“We once again offer our deepest sympathies to Mr Farrington’s family for the loss of their much loved family member.”