A failure by doctors to recognise the symptoms of renal failure and a delay in carrying out a blood test on a 91-year-old woman played a part in her death, an inquest heard.
Maisie Wilson died on March 3 at Hinchingbrooke Hospital, a week after being admitted for treatment for breathing difficulties.
Dr Robert Buttery, a consultant respiratory physician, told an inquest in Huntingdon that Mrs Wilson underwent a CT scan which revealed a build up of fluid around her lungs and also showed signs of cancer.
However, contrast dye used in the CT scan caused “an acute injury” to Mrs Wilson’s kidneys which was not recognised by doctors.
Dr Buttery told assistant coroner for Cambridgeshire and Peterborough, David Morris, that Mrs Wilson, was put on a drain to clear the fluid in her lungs and she was given a blood test on February 27, to check creatinine levels in her blood – a key indicator of kidney function.
A second blood test was to be carried out the following morning.
The inquest heard, however, that it wasn’t until later in the day that a junior doctor discovered that the blood test had not been done.
Medical director of Hinchingbrooke Health Care NHS Trust Dr Catherine Hubbard said: “He explained this to his superior who made the decision that it could be postponed until Sunday morning.”
According to Dr Buttery the blood test was not carried out until Sunday evening but by this time Mrs Wilson had deteriorated to a point that no more could be done for her.
“She had been reviewed by the palliative care team over the weekend,” added Dr Buttery.
Mrs Wilson’s family, who were present at the inquest, questioned whether mistakes were made in the care of the retired factory worker, of Lyons Court, Chatteris.
“I think her care was good but earlier realisation of her renal failure would have been useful, but she was a very old lady,” said Dr Hubbard.
In his conclusion, Mr Morris said that Mrs Wilson’s “renal failure was not recognised at an early stage and was not monitored in a timely manner.
“If the blood test had been carried out I am satisfied that on the balance of probabilities she would not have died at the time she did.”
He concluded that there were other factors that contributed to Mrs Wilson’s death including the spread of cancer and kidney disease.
As a result of Mrs Wilson’s death, Hinchingbrooke Hospital carried out a review into their procedures of recognising vulnerable patients who could be at risk of acute kidney injury and have since implemented a new computer programme to examine factors relating to kidney failure. Training has also been carried out with doctors and nurses at the hospital to identify patients who are at a higher risk of kidney failure.