A CORONER has twice been forced to adjourn an inquest into the death of a man who died in Cumberland Infirmary due to the hospital being unable to confirm if or how vital medication was administered.

William Henderson, 53, of Gretna, died on March 27 in hospital in Carlisle three days after he woke up in bed and ‘realised he couldn’t talk’, according to his partner of over 20 years, Gillian Rosado.

Ms Rosado’s statement, heard at Cockermouth Coroner’s Court, heard how Mr Henderson, a window cleaner who was ‘fit and well, and had no medical problems’, woke on at 8.30 in the morning and was unable to speak.

Ms Rosado called an ambulance at around 10.50am, which Mr Henderson was able to walk to.

By the evening of March 27, after rapidly deteriorating following two bleeds on his brain, Mr Henderson, a ‘loving father and stepfather’, was pronounced deceased.

Upon admission to hospital, Mr Henderson underwent thrombolysis at 12.49pm, an emergency procedure that is used to dissolve blockages in blood vessels, but which carries a risk of bleeding.

The doctor that took the decision to thrombolyse Mr Henderson told the assistant coroner for Cumbria, Mr Robert Cohen, that she took the decision to use the procedure because Mr Henderson was ‘fit’ and ‘a young person’, and that subtle changes in his CT scan indicated that a stroke had happened less than four hours earlier, after which time, the court heard, guidelines are that thrombolysis carries too great a risk to be performed.

She stated that a ‘priority' was to get Mr Henderson’s blood pressure, which was ‘extremely high’, down.

She said he was ‘the most difficult patient in seven years’ to lower their blood pressure.

An initial CT scan on March 24 showed no bleed on the brain, but after rapid deterioration in his condition, a second CT scan was performed, which showed two bleeds had then occurred on Mr Henderson’s brain.

A statement by the doctor who treated him in the stroke unit said that he had prescribed ramipril (an anti-hypertensive drug), to be administered intravenously, to control his blood pressure.

The decision was taken, as his blood pressure was ‘much better controlled’, to administer the ramipril via a naso-gastric tube on March 25, due to this being a ‘less labour-intensive' method, which ‘allows the patient greater periods of rest’.

This was ordered by the consultant, but Mr Henderson’s family reported that the tube was inserted the following day (March 26), and hospital records show that the ramipril was administered orally, despite family assertions that Mr Henderson was unable to swallow, thus was not receiving the medication.

Mr Cohen said: "The doctor’s statement says as his blood pressure was much better controlled, he changed his administration to naso-gastric tube. This indicates the doctor thought he needed a naso-gastric tube (as he was unable to swallow), and the family are right.

“Could the absence of ramipril and high blood pressure have worsened the bleed?

“If a patient is bleeding and they don't get their hypertension treatment, that is dangerous. If there is a reason to conclude that the anti-hypertensive was taken off, that is causative.

“At the moment, it certainly looks like it’s possible.”

He went on to say: “The consultant who prescribed ramipril expected it to be administered via naso-gastric tube. Either the record is wrong or the person who administered the drug said he is able to swallow.

“We’re going to need the nursing record to find out how that has happened.

“On the face of it, the fact is it says ramipril was administered orally. I need to know, is the family wrong?

“We need an answer to this conundrum, and I’d like to know what his blood pressure readings were in the period between those times when a naso-gastric tube was not in place.

“We need that rapidly.”

Mr Cohen ordered the information to be provided to the court by the hospital Trust within 14 days.

Ms Rosado said: “He was everything to us and we loved him.”