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NEGLECT CONTRIBUTED TO TEACHER`S DEATH

By County Press Reporter - Friday, June 22, 2007
A VERDICT of accidental death contributed to by neglect was recorded at the inquest into the death of teacher Margaret Pettitt at St Mary’s Hospital, Newport.
Mrs Pettitt, 53, deputy headteacher of St Thomas of Canterbury Primary School, in Newport, was admitted to St Mary’s in December, 2005, after a GP suspected she was suffering from a deep vein thrombosis and possible pulmonary embolism, but it was almost 15 hours before she was given any clot-busting drugs.
According to an expert witness, eminent retired consultant surgeon Anthony Roberts, two different doctors at the hospital conducted a test on Mrs Pettitt — the Homan’s test, now considered obselete because it could cause the clot to start moving — although this was not said to have contributed to her death.
Mrs Pettitt, who was married to David, former director of children's services at the IW Council, died on December 6, 2005 of a pulmonary thrombo-embolism (blood clot on the lung) and deep vein thrombosis, around 12 days after having a plaster put on her left leg at St Mary’s after tripping on stairs at school and straining ligaments as she worked on a Sunday to prepare for an Ofsted inspection.
She went to Accident and Emergency the next day but instead of resting it and keeping it elevated as advised, she went to work for the next two days because of the Ofsted inspection.
It was only after returning to St Mary’s that a plaster was fitted on Thursday, November 24, after which Mrs Pettitt stayed at home in Westhill Road, Shanklin, for the next nine days.
A call was made to NHS Direct after Mrs Pettitt suffered excruciating stomach pains but because of a mistake, the first call was logged as no action to be taken and she was not referred to the out-of-hours IDOC service.
Coroner John Matthews said this was simple human error, but did not amount to neglect in the legal form.
It was not until 11am the following day, Sunday, December 4, that Mrs Pettett was diagnosed with a suspected DVT and pulmonary embolism by Dr Louay Al-Mukhtar at IDOC, who arranged for admission to the medical assessment unit at St Mary’s.
Mr Matthews said: “This did not happen and it seems she had never received any medication at all — and this is the crucial matter — until the evening of the Sunday and then only part of the medication, the heparin.
“This is a fast-acting agent but the warfarin was not administered until Monday, December 5, and would not have had any effect on her for 48 hours.
“The administration of the heparin might have had a marked effect if it had been done on the Sunday morning. There has been no explanation from the hospital as to why there was this delay in formal diagnosis and, more importantly, the administration of medication, no explanation of any satisfactory nature at all,” said Mr Matthews.
Mr Matthews said it was unfortunate that Mrs Pettitt was seen by so many different doctors, without any form of co-ordination.
Her condition worsened overnight on December 5 and she died after suffering four cardiac arrests, despite the strenuous efforts of staff in the intensive care unit to resuscitate her.
After the inquest Mr Pettitt said he would be seeking legal advice, adding he was “surprised and dismayed" the hospital was not represented at the inquest.
  • Full story in the Friday, June 29, County Press.