A 65-year-old woman died after the medication she desperately needed was missed or omitted - and a Darlington hospital has been slammed by a coroner for their care mistakes.

Janet Rice, 65, died at Darlington Memorial Hospital after arteries in her lungs and brain became clogged, following an operation to fix her broken hip.

Now, it has emerged that staff at the hospital failed to give Ms Rice the necessary prophylactic anti-coagulant medication "consistently" - missing it after she was transferred between hospitals, and then omitting medication on five further occasions. 

Ms Rice had declined medication whilst in a state of "acute delirium" caused by her condition - but questions have emerged as to whether she had the mental capacity to turn down treatment.

In medical records, Ms Rice was said to be confused, paranoid, and agitated, but nurses failed to assess her capacity to decline drugs, meaning no "best interest decision" was made to administer drugs without permission or consider alternate treatment options. 

At an inquest, the trust accepted that this omission of anti-coagulant drugs contributed "more than minimally" to the development of the pulmonary embolism. 

Assistant coroner Janine Richards has now said changes have to be made at County Durham and Darlington NHS Foundation Trust to ensure the same mistakes do not contribute to future deaths. 

Ms Richards has highlighted problems with the patient safety report - an internal investigation carried out by the trust - as the report was only received on the first day of the inquest, 16 months after the 65-year-old's death. 

In a Prevention of Future Deaths report, the coroner writes: "The concerns raised in this Inquest have been well known to the Trust for a considerable period of time and the concern is that lessons cannot be learned in a timely fashion if patient safety investigations are so significantly delayed."

Issues about the content of the report were also raised, as the report "is not a comprehensive and robust review", as it did not address omissions because of Ms Rice's hospital transfer, nor does it go into sufficient detail about missed medication administrations.

At the inquest, more incidents of missed anticoagulant medication came to light from the independent report into Ms Rice's death. 

The coroner added: "[The trust's] remit and action plan are limited to the community hospital only, and do not consider or address the further instances of omission in the acute hospital setting. 

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"There was a continued failure to carry out a capacity assessment and any subsequent best interests decision-making process, failure to escalate these issues, or to consider any alternative treatment to reduce the high risk of deep vein thrombosis or pulmonary embolism."

The coroner has asked the hospital to deal with problems that emerge in the acute hospital setting, as well as provide further training on capacity and best interests decision-making. 

The trust now has to respond to the coroner's report within 56 days, detailing action taken or proposed to be taken.

A spokesperson for County Durham and Darlington NHS Foundation Trust said, “We send our sincerest condolences to Janet’s family and take the findings of this report extreme seriously. 

"We will be responding to the Coroner within the required timescales and it would be inappropriate to comment further whilst that process is ongoing.”