NEGLECT at the city's hospital contributed to a disabled woman's death, a Worcestershire coroner found.

Kelly Stevens, who had profound learning and physical disabilities, died after doctors failed to spot she had low sodium levels.

The coroner found a string of issues with her care at Worcestershire Royal Hospital including doctors copying and pasting out-of-date care plans and a failure for any one consultant to take charge of her case.

Worcestershire Acute Hospitals NHS Trust apologised unreservedly for their failings and said their care had fallen short. 

Worcestershire's Senior Coroner David Reid found Ms Stevens died from complications associated with an excessively low and unrecognized sodium level. He said neglect by Worcestershire Royal Hospital contributed to her death.

Mr Reid discovered the hospital routinely “copied and pasted out-of-date care plans by previous doctors," so people had a mistaken view of her current care plan.

The 42-year-old had to receive all nutrition, hydration and medication via a tube, which was given to her when she was first admitted to the hospital on December 28, 2023. 

She was diagnosed with a likely pseudo-bowel obstruction, and a plan was made for her care with drugs to be given to her through a drip.

However, her intake of the drugs was never properly recorded, her electrolyte levels were not monitored and her notes revealed evidence of routine “copying and pasting” of out-of-date care plans.

The Prevention of Future Death Report, issued by the coroner after an inquest into her death, found that during most of Ms Stevens's admission, she was placed as a medical outlier on a surgical ward. This meant no one consultant was in overall charge of her care, leading to issues not being identified.

Ms Stevens then suffered from a seizure during which she also vomited because she had excessively low sodium levels, which had not been recognised. 

She went on to develop aspiration pneumonia and, despite treatment, declined and died in hospital on January 3, 2024. 

Sarah Shingler, Chief Nursing Officer at Worcestershire Acute Hospitals NHS Trust, said: “We would like to express our deepest condolences to Ms Stevens’ family for their loss. We also apologise to them unreservedly for the failings which contributed to her death, these events fell a long way below the standards we set for ourselves.

“We have carried out a full investigation, and as a result, a comprehensive action plan has been put in place, including targeted education around prescribing, sharing learning and best practice with colleagues, as well as additional oversight to help avoid events like this happening in future.

"In addition, as soon as the issue with the copy and paste function became apparent, we made immediate changes to our digital patient record system to remove this functionality.

"Ms Stevens’s family have been kept updated on our investigation process throughout, and the full set of actions we are taking as a result will be shared with them."

The Prevention of Future Death Report was published on September 25, the day after an inquest into Ms Stevens's death.