POOR treatment was not to blame for the death of a ‘lively and vivacious’ 22-year-old who died in her parents’ arms four days after being admitted to hospital.
But an inquest into the death of Jenny Bray was told Queen Alexandra Hospital in Cosham has retrained its nurses as a result of her death – and it also heard that her family were angered by how she was treated on one ward.
Miss Bray, of Drayton in Portsmouth, died at the hospital in July 2013, four days after being admitted complaining of chest pain and vomiting. The inquest heard she had been diagnosed with anorexia and an eating disorder from the age of 14 and had a body mass index of 12 – far below the normal 18.5.
She also claimed to have been consuming a bottle of wine or three bottles of cider a day but told doctors she wanted to improve her situation and make changes.
The inquest, at Portsmouth Guildhall, heard Miss Bray’s parents had a number of concerns about their daughter’s treatment.
But none of the points raised were found to have contributed to her death.
Giving a narrative verdict, Portsmouth assistant coroner Robert Stone said: ‘I don’t think there is any element of blame on the hospital, although there are areas in which things could be tightened up and they are being tightened up and I am glad to hear that.
‘Something occurred which caused her to deteriorate and she died. There was nothing in her treatment which appears to have contributed to her death.’
Doctors agreed at the inquest that Miss Bray had been given too much paracetamol for someone of her weight, but a post mortem and toxicology tests showed the extra dosage of the drug had no ill effects on her system.
It was also revealed data about her condition was accidentally recorded onto the wrong chart on the electronic system used by nurses in the ward where she was being cared for.
But this also was found to have had no negative effect on her treatment.
Nevertheless, the hospital carried out an internal incident investigation and made several recommendations as a result of Miss Bray’s death.
As a result, nurses were retrained in how to use the computerised notes system, called Vitalpac, and reminded to take care when entering patients’ data.
Miss Bray’s father David also criticised the care she received from staff in one of the wards in which she stayed at the hospital – but praised doctors and nurses in the intensive care unit who looked after his daughter during her final moments.
On one occasion, Miss Bray’s parents arrived to visit her and found her crouched in a toilet, disoriented and vomiting.
Mr Bray said: ‘I went to the nursing station and said we were very worried about her condition and they said they would send someone along as soon as they could.
‘I waited and went back later and as I glanced to my left there were three white-coated individuals with tea in their hands.
‘I was told all the doctors were busy.
‘I did lose my temper a bit.’
Miss Bray’s condition deteriorated and she fell unconscious before being taken for intensive treatment.
Mr Bray told the coroner’s court how he saw ‘light at the end of the tunnel’ when he felt his daughter squeeze his hand one day while she was in intensive care.
But at one point she suffered a heart attack and although she was revived, she never made a full recovery.
‘We discussed Jenny’s prognosis and what she would be like if she got through and it didn’t bear thinking about,’ said Mr Bray.
‘A decision was made to switch off the equipment and see if there was any response but there wasn’t. We asked if we could hold Jenny without the equipment in the way so it was moved and she passed away in our arms.’
Doctors, nurses and pathologists who were all involved in Miss Bray’s treatment or the investigation into her death gave evidence at the hearing yesterday.