Airdrie & Coatbridge Advertiser
OAP died after junior doctor sent her home
Poorly pensioner was packed off in a taxi at 2am
A woman tragically died just 48 hours after she was discharged from University Hospital Monklands.
The elderly patient was sent home by a junior doctor – who was just two years out of medical school – by taxi in the middle of the night, despite still being in pain.
The 78-year-old – known only as “Mrs C” – had earlier been taken to the Airdrie hospital’s A&E department by ambulance at 9.58pm on May 2 this year, complaining of severe stomach pains and vomiting.
She was also suffering from multiple health problems, including high blood pressure and pulmonary hypertension – and was the victim of three previous heart attacks and a stroke.
The woman was seen by a “middle grade” emergency doctor at midnight, who suspected she might have a blockage or perforated intestine.
Further tests were carried out and she was referred to the on-call surgical team for a specialist opinion 20 minutes later.
A junior doctor, described by an adviser to the ombudsman as “relatively inexperienced”, reviewed her case and concluded that it was safe to discharge her within the hour, with gastroenteritis given as the probable diagnosis.
She was not given any pain relief – despite recording three out of four on the pain scale – and was put in a taxi at 2am.
Her stunned husband, who did not know that she had been discharged, said he found his stricken wife in her night clothes, knocking on the door and in pain.
Sadly, she died at the couple’s home two days later.
Scottish Public Services Ombudsman, Rosemary Agnew, revealed she was “critical, even shocked” by the care given to the pensioner.
Ms Agnew said she had found “significant failings” in her care and ordered NHS Lanarkshire to apologise to the woman’s husband.
She also outlined a series of recommendations to improve care, including telling the health board that in such cases, patients should not be discharged without senior doctor oversight.
In response to the discharge of the elderly patient, Ms Agnew said: “I am critical, even shocked, that this situation occurred at all.
“I am particularly critical that the board’s own complaints investigation failed to identify any concerns about the circumstances involving an elderly and frail patient with multiple health problems being discharged home by taxi in the early hours of the morning.
“I conclude that it was unreasonable to discharge Mrs C in the early hours of the morning and not to have discussed this with Mr C in advance.”
A post mortem report ruled the cause of the woman’s death as ischaemic and valvular heart disease.
However, an inquir y concluded that she may also have suffered acute pancreatitis, which was not identified because a “grossly abnormal” blood test result was ignored.
NHS Lanarkshire admitted that a full drug history had not been recorded.
The first doctor had failed to record significant parts of her medical history.
The record of examination of her respiratory system, cardiovascular system and abdomen was described as “brief and lacking in detail.”
The doctor had also failed to take into account that women with heart disease are more likely to complain of abdominal pain and vomiting than men.
The inquiry concluded: “Had a more senior doctor overseen Mrs C’s care and due attention had been given to the test result, she would have been admitted to hospital which may have avoided her death.”
NHS Lanarkshire acute divisional medical director, Dr Jane Burns, said: “We regret any instance where we fail to provide the highest standards of care for our patients and we will contact the complainant directly to offer our sincere apologies for the failings identified in the report.
“We have fully accepted the recommendations within the Ombudsman’s report and will develop an action plan to address them.
“The lessons learned will be shared to help avoid similar occurrences in future.”
I’m critical, even shocked this situation occurred ... it was unreasonable to discharge Mrs C