WOMAN, 78, SENT HOME TO DIE AFTER BLOOD BUNGLE
AN elderly woman died after being sent home from hospital despite having “abnormal” blood tests.
The pensioner had complained of severe stomach pains and vomiting.
A WOMAN died 48 hours after a “significantly abnormal” blood test result was ignored and she was sent home in pain by a junior doctor, an inquiry found.
The Scottish Public Services Ombudsman, Rosemary Agnew, was “critical and shocked” by the case involving a 78-year-old woman at Monkland’s Hospital in Airdrie.
The pensioner was taken to A&E by ambulance shortly before 10pm on May 2, complaining of severe stomach pains and vomiting.
She also suffered from multiple health problems including high blood pressure and pulmonary hypertension and had suffered three previous heart attacks and a stroke.
The woman, who has not been identified, was seen by a ‘middle grade’ emergency doctor at 12am, who suspected she might have a blockage or perforated intestine.
Further tests were carried out and she was referred to the oncall surgical team for a specialist opinion at 12.20am.
A “relatively inexperienced’ doctor reviewed her case and concluded that it was safe to dis- charge her home within the hour, with gastroenteritis given as the probably diagnosis. She had not been given any pain relief, despite recording 3 out of 4 on the pain scale.
She died two days later at home.
A post mortem report ruled the cause of death as ischaemic and valvular heart disease.
However an inquiry concluded that she may also have suffered acute pancreatitis, which was not identified because a “grossly abnormal” blood test result was ignored.
The Scottish Public Health Ombudsman identified “significant failings” in her care.
An advisor to the inquiry said the junior doctor was of Foundation Year Two level, a level not considered by the Royal College of Surgeons to be experienced enough to give a diagnosis in this case.
The doctor had failed to take into account that women with heart disease are more likely to complain of abdominal pain and vomiting than men.
There was also evidence to demonstrate that Mrs C had been offered no pain relief despite the fact she was experiencing moderate to severe pain.
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 been given to the test result she would have been admitted to hospital which may have avoided her death.”
The inquiry found that the abnormal blood test result was also overlooked a further two times, during the health board’s investigation. Two complaints were upheld against NHS Lanarkshire for a failure to provide reasonable care and the board has been given a deadline to implement a series of actions.
Dr Jane Burns, NHS Lanarkshire acute divisional medical director, 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.”