Hillsborough nurse Dorrie who died from head injury 'let down by health service'
The son of a retired nurse from Hillsborough who died after hitting her head at home has said she "was devoted to the health service that has let her down".
Mary Kilpatrick, known as Dorrie, was 78 when she fell in her home on March 3, 2014 and passed away almost three weeks later.
Her son Charles Kilpatrick told an inquest in Belfast's Laganside Courts yesterday she was a "very popular lady in Hillsborough" who "spent her life caring for others".
After her accident she was taken immediately to the Royal Victoria Hospital where a CT scan discovered a small bleed inside the brain.
Discharged the following day, doctors were satisfied Mrs Kilpatrick was not in danger. However, it was revealed she was given no written discharge advice - usually required for head injury patients - and was mistakenly prescribed the wrong dosage of the anti-coagulant drug Enoxaparin.
On March 19 she had arranged to meet a friend for lunch near Hillsborough.
She began to feel unwell and lost consciousness by the time she got home.
Surgeons at the Royal Victoria Hospital fought to save her life, but she had suffered a rapid and larger bleed of the brain and died in intensive care two days later on March 21.
Despite the errors in her discharge, Coroner Joe McCrisken ruled that even if the correct procedures had been followed, the outcome was likely to have been the same.
But he added that the case had highlighted failings in the health care system which could have put other patients in danger.
Speaking in court her son said: "It's a very difficult day for the family.
"We would like to see reassurance to make sure the events don't happen again."
Mrs Kilpatrick trained as a nurse in 1956, leaving the profession after three years to raise her family and do charity work.
"She spent her life caring for others, she was a caring person who looked after my father before his death," her son said. He added that his mother and late father John, who worked was a farmer, "sacrificed so much" to send their sons to university.
In his finding, Mr McCrisken said: "This lady's family told me this was a lady who cared for other people throughout her entire life working as a nurse and in her voluntary work with the church.
"In their view it was not unreasonable that when she needed help that she should have been provided with a good standard of care.
"Her family have been forthright in expressing their view Mrs Kilpatrick was failed by the health care system."
The coroner said that although Mrs Kilpatrick received excellent medical care on the day of her fall he said it was "not satisfactory" that she, her family or GP were not given discharge advice on her medication or what to do if she became unwell.
He said steps should be taken to avoid errors in prescribing medication, but was "satisfied the additional dose made no material difference to the outcome".
He added: "I'm pleased to hear a number of recommendations have been made following this lady's death that have been acted upon and work continues to improve standards and improve care." Mr McCrisken told the family they had done all they could for their mother.
"Having assessed all the evidence it seems to me that your mother's (sudden) bleed and subsequent death was a tragic event which probably couldn't have been forseen by anyone at all."