THE John Radcliffe hospital has been urged to make improvements following the death of an elderly patient who died after staff failed to take any action to reduce the risk of a fatal blood clot forming while she awaited surgery.

Oxfordshire coroner Darren Salter recorded an accidental verdict following the inquest into the death of 74-year-old Marian Grant in September.

However in a report to prevent future deaths, the coroner has since urged hospital chiefs to improve care at the Headington hospital.

Chiefly among the coroner’s concerns was the patient records system which had allowed as many as 27 doctors and nurses to ultimately ignore warnings and alerts that treatment to prevent an embolism (a blockage in a blood vessel) had not been undertaken.

A further concern was raised over the level of care given to trauma patients staying on non-trauma wards.

Mrs Grant was taken to the emergency department at the John Radcliffe after breaking her hip in a fall on Saturday, April 14 last year while visiting her grandson at Oxford University.

Doctors had intended to carry out a hip-replacement operation the following day, however, due to a number of urgent surgery cases, Mrs Grant was temporarily housed on the neuro-science ward since there were no free beds on the trauma ward.

She was taken to theatre on the Monday but died during the operation.

A post mortem examination revealed a ‘massive pulmonary embolism' from deep vein thrombosis in both legs, which, according to the inquest, had likely been caused by ‘immobilisation’ in a hospital bed.

In Mr Salter's report it was revealed how a system designed to alert clinical staff of the need to take action to reduce risk of an embolism was easily sidestepped, while concerns over a lack of safeguards on non-trauma wards was also highlighted.

Medical Director at OUH, professor Meghana Pandit, said an audit had since evaluated the standard of care across the trust for trauma patients.

She added: "Following this audit we took a significant number of steps to ensure this situation doesn’t happen again, including increased and improved reviews of trauma patients located outside of the unit and adjusting our electronic patient record system to improve alerts around prescribing particular medications."