'Lessons learned' after dialysis patient bled to death at Shrewsbury hospital, says coroner

Shropshire coroner John Ellery gave a conclusion that Mohammed Ismael “Bolly” Zaman died following a system failure and individual neglect at Royal Shrewsbury Hospital, when his dialysis machine became disconnected and he lost three pints of blood in seven minutes.

But Mr Ellery said he was satisfied the Shrewsbury and Telford Hospitals Trust had learned and acted upon its mistakes.

See also:

• Hospital 'is safe', insists dialysis patient after diabetic man bled to death

• Staff criticised after diabetic bled to death at Shropshire hospital

• Safety rules ignored before diabetic man bled to death, inquest hears

• Family suing Shrewsbury hospital after pharmacy worker bled to death during dialysis

In his final remarks, he said: “A considerable amount of time was spent on the lesson learning exercise.

"I was satisfied as to two separate things regarding the trust’s response.

"Firstly they have carried out a prompt and thorough investigation themselves as to how it occurred.

“It indicated they interviewed every member of staff on the unit that day and I am satisfied that there was nothing more they could have done to seek to identify that person.

"More widely I am satisfied that they have learned many lessons from Bolly’s tragic death.”

Measures

Trainee pharmacist Bolly, 31, from Telford, was a Type 1 diabetic, and had suffered a number of health problems in the months leading up to his death.

His inquest heard that he felt cold in his dialysis room and was covered up with blankets to keep warm.

However, that was contrary to safety guidelines as patients lines need to remain exposed so doctors can gain quick access if there is a problem.

When the alarm went off on Bolly’s machine, an unidentified nurse pressed the “reset” button, without checking his lines were safely connected.

Mr Ellery made it clear that it wasn’t a requirement for the inquest to find out who reset the alarm.

Barbara Soden, chairwoman of Shropshire and Mid Wales Kidney Dialysis Patients Association, said: “Measures have been implemented to encourage patients not to have lines covered.

"We have had new measures put in place to keep us safe so this will not happen again.”