A BRIERLEY Hill widow died from an infection after missed opportunities to give her antibiotics but a coroner has concluded there was no evidence she would have survived without the delay in treatment.

Brenda Askins, aged 81, of Chelmar Drive, Pensnett, died at Netherton Green step down unit on April 14 - having been discharged to the facility for rehabilitation on March 23 after a stay in Russells Hall Hospital following a fall and treatment for infected leg ulcers.

Dudley-born Mrs Askins had a number of health issues including rheumatoid arthritis, heart failure, chronic kidney disease and failing eyesight, but she had been living alone with help from carers and family prior to her hospital admission.

On April 10 she was seen by Dr Valentina Price, who prescribed antibiotics for a possible urinary tract infection.

But Mrs Askins never received the medication due to a series of misunderstandings.

It was only four days later, at around 11.50am, on April 14 that the doctor thought realised Mrs Askins had not had any medication. She said the pensioner appeared confused and when she checked on the electronic records system - no antibiotics were found.

A call was made to Boots pharmacy which confirmed the prescription had been delivered on April 11 and signed for by a member of staff at the care home but the antibiotics had gone unnoticed in a box filled with protein supplement drinks until the 14th.

Once found, the medication was due to be given at the next drug round at lunchtime but Mrs Askins deteriorated rapidly and passed away at around 2.15pm.

Area coroner for the Black Country, Joanne Lees, said by the time the antibiotics could have been administered Mrs Askins was in septic shock and "no actions taken by anyone at that point" could have changed the outcome - especially as the pensioner had been the subject of a DNAR (do not attempt resuscitation) order and there was a 'not for hospital admission' care plan in place.

She told Black Country Coroner's Court as the inquest concluded on Wednesday (July 29): "There were opportunities missed to administer antibiotics and optimise Brenda's chances of survival."

However, she was "not satisfied the delay in administering antibiotics to Brenda contributed to her death" which was due to urosepsis, and contributed to by extensive coronary artery calcification (a build up of calcium in the arteries).

She said it was "possible" Mrs Askins may have responded to the broad spectrum antibiotics prescribed but she "did not hear any evidence" that she would not have gone on to develop urosepsis.

She offered her "very sincere condolences" to the family as she concluded Mrs Askins' death was due to natural causes.

Managers at Netherton Green care home admitted there had been staffing shortages at the time of the incident, with the interim manager off sick due to Covid-19 symptoms.

But they told the hearing they had since implemented a raft of measures, including supervision of staff, scrapping the electronic records system and ensuring there are two nurses on duty during the daytime, to try to prevent any such incident happening again - and they said they would be meeting with bosses from Boots pharmacy to resolve concerns regarding the packaging of medication delivered to the home.

In light of the changes outlined by care home manager Pauline Steed and Barbara Morby, who carried out an investigation into the incident, the coroner said: "I'm satisfied concerns have been addressed by Netherton Green. I'm satisfied there's been learning following these issues identified during the course of the investigation."

Mrs Askins' daughter-in-law Donna Askins told the hearing: "It's been very traumatic for us as a family."

She said Mrs Askins had been widowed seven years earlier and she had numerous long-term health issues for many years but she "never really let it get her down".

Unable to visit after the coronavirus crisis worsened and lockdown measures were introduced, she said it was "heartbreaking for us and must've been even more heartbreaking for her" as she told how she and her husband Mark had seen his mother through the window - slumped in her chair and shaking - two hours before she passed away.