TWELVE mistakes made by health professionals caring for an elderly grandmother caused her death, a coroner told an inquest.

A full inquest involving expert witnesses from across the country threw light on the death of Eveline Birtwell two and a half years after she died.

Coroner Michael Singleton listed a series of mistakes by medical staff caring for Mrs Birtwell in Blackburn Royal Infirmary and in the White Ash Brook Nursing Home, in Thwaites Road, Oswaldtwistle.

He said: "It is quite clear that there has been a breach of duty of care. I am satisfied that that breach of duty of care did in fact cause or have a clear link to the death of Mrs Birtwell."

But Mr Singleton did not accept that the neglect was so gross as to be criminal or that at any one time there had been a gross error committed by one person.

He recorded a verdict of accidental death. The Crown Prosecution Service had previously decided not to press criminal charges.

Today Mrs Birtwell's family spoke of their frustration at the verdict which had come at the end of a two and a half year nightmare. Daughter Anita Raven, of Cranbourne Drive, Accrington, said: "I am very disappointed with the verdict, but I couldn't expect anything else.

"I feel let down after all this time. The last two years, three months have been a nightmare. Hopefully we can now move on."

Mrs Birtwell's husband of 61 years, Henry, was too upset to attend the inquest, but believes that someone should shoulder the burden of his wife's death.

Mr Birtwell, 89, said: "There were a lot of mistakes made and nobody will take responsibility for them. Why? Right from the beginning I felt they were holding something back."

The couple met through a shared love of ballroom dancing. This Sunday would have been Mrs Birtwell's 85th birthday.

Her husband said: "I miss her terribly. There isn't a day goes past that I am not thinking of her.

"It would have been her birthday on Sunday so I have given my daughter some money to get some flowers. I have left instructions for me to be buried with her then we will be together always. Nobody could part us then."

Mrs Birtwell fell at her home in Elmfield Street, Church, on August 21, 2001.

She was taken to Blackburn Royal Infirmary and was treated overnight.

On August 22 it was decided by consultant Dr El Sayed Soliman that Mrs Birtwell could leave the hospital for intermediate care, the inquest heard.

Mr Singleton said that at the hospital it was decided the drug Diltiazem, used by Mrs Birtwell to control angina, should be stopped and a beta blocker drug called Sotalol be doubled in dosage.

On leaving hospital to go to White Ash Brook Nursing Home a bag of Mrs Birtwell's possessions was taken with her which contained old packets of the drugs for Diltiazem and Tildiem Retard, the inquest heard. These are both the same drug, under different names, used to control angina.

Mr Singleton said that at the home, run by GPs Dr Arthur Manuel and Dr John Dixon, a nurse, Deborah Jackson, took it upon herself to write the names of Diltiazem and Tildiem Retard on Mrs Birtwell's medical administration record.

She then phoned Simon Smith's Brierfield Pharmacy to order the Tildiem Retard telling the staff there that Dr Dixon would write a prescription later in the day, Mr Singleton said.

Mr Singleton added that during the next three days Dr Manuel signed Mrs Birtwell's medical administration record without properly noting the drug names or realising they had been written by a nurse.

This meant for the days leading up to her death Mrs Birtwell was taking three different types of the same drug used to combat angina and reduce blood pressure, the inquest was told.

On day one of the inquest, the nursing home matron Janet Briggs admitted drug guidance procedures had not been followed.

Dr Steven Saltissi, a consultant physician from Liverpool, gave expert evidence in the case.

He said: "It is my opinion that it is much more likely than other possibilities that Mrs Birtwell died due to excessive and inappropriate prescription of Diltiazem."

The coroner listed 12 mistakes by East Lancs health professionals in the care of Eveline Birtwell:

1. A decision by doctors in the medical assessment unit of Blackburn Royal Infirmary to stop one drug being given to Mrs Birtwell, Diltiazem, and double the dose of another drug, Sotalol, was not recorded in the medical records.

2. The medication prescribed at the hospital and the medication brought to the hospital by Mrs Birtwell were placed in a grey property bag to take to the nursing home without sufficient distinction between the two.

3. Mrs Birtwell was suffering from dementia and should not have been considered for an intermediate care bed because of this, under hospital guidelines.

4. At White Ash Brook Nursing Home nurse Deborah Jackson took it upon herself to record on Mrs Birtwell's medical assessment record (MAR) the drugs Tildiem Retard and Diltiazem. No doctor had authorised this or signed the form as being appropriate.

5. Deborah Jackson put the drugs that Mrs Birtwell had taken with her to hospital into the drugs trolley.

6. Nurses at the home started dispensing Diltiazem despite the MAR chart not containing a doctor's signature.

7. Tildem Retard was considered as being out of stock only hours after Mrs Birtwell was admitted from hospital. The empty box was in fact brought by Mrs Birtwell to the hospital from home and was still in her possession at the nursing home. Nurses and Dr Dixon should have noticed that something was amiss for Mrs Birtwell to apparently be out of stock so soon.

8. No hospital prescription pads were available. Care should have been made to ensure the alternative arrangements that were put in place to obtain Tildiem Retard contained checks and balances.

9. There was a failure within Simon Smith's Brierfield Pharmacy to make appropriate enquiries as to whether Tildiem Retard was appropriately prescribed.

10. Dr Arthur Manuel signed the blank spaces under the names of the drugs nurse Deborah Jackson had written, therefore missing an opportunity to see a mistake had been made.

11. There was no record of issuing of the prescription or no evidence to say conclusively whether a prescription was ever written by Dr Dixon. Pharmacist Mr Smith also failed to keep a record of the locum at the pharmacy at the time as Mr Smith was away.

12. The hospital pharmacy failed to spot any problems with Mrs Birtwell's MAR chart when it was faxed there when an antibiotic was later prescribed by Dr Manuel.