Woman died after routine check caused haemorrhage
AWOMAN died in agony from a bungled bowel examination after being told that help from an ambulance, A&E and even a GP would all involve a wait of at least two hours.
Susan Longden, 69, died of internal bleeding after suffering a perforated bowel during a routine colonoscopy appointment.
Mrs Longden, pictured, endured “excruciating pain” in the hours that followed, but nurses said it was probably trapped air when her husband David repeatedly phoned for help.
He described the severity of her pain as “9/10” in a number of desperate calls to the endoscopy department that afternoon.
A nurse at the unit told David to make Susan a cup of tea and avoid taking her to A&E because there was a three-and-a-half-hour wait, an inquest into her death heard.
David phoned NHS 111 for advice in the evening when the pain persisted and was told an ambulance would take two-and-a-half hours to arrive.
NHS 111 requested an ambulance but this was changed to a call requiring an out-of-hours doctor, who was also going to take two hours to arrive.
Susan’s condition deteriorated and she fell unconscious and David had to perform CPR on his wife on their bathroom floor.
She died in the early hours of the following morning – February 1 this year – in hospital.
David, who lived with his wife in Weston-super-Mare, Somerset, describes her tragic death as “preventable” and “avoidable”.
A statement on behalf of the family said the investigation into her death had been an “extremely traumatic process” and that “opportunities were missed which could have saved Susan’s life”.
It read: “Although a perforation or rupture of the spleen maybe a rare complication of a colonoscopy, given the extreme pain reported to them by Mr Longden, staff at the unit acknowledged that they regarded a perforation as a possibility and they also recognised that this could be a serious and life threatening condition.
“The family find it difficult to understand why they were not warned of this possible complication and they were not immediately urged to bring Susan into the hospital or to call for an ambulance. Had Mr Longden been given this advice there is no question that he would not have brought her straight into the hospital, only a six-minute drive away, or called for an ambulance.
“The family also believe that had the NHS 111 service identified the severity of Susan’s condition, an ambulance could have been called sooner and Susan may still be alive.
“The family feel that there should have been immediate recognition that Susan needed urgent treatment and that opportunities were missed which could have saved Sue’s life.
“It is extremely hard to come to terms with her preventable death.”
Describing the moment Susan collapsed, David told three-day inquest at Flax Bourton near Bristol: “She was complaining of terrible pain in her stomach and she was screaming out in agony.”
Assistant coroner Dr Peter Harrowing did not blame healthcare professionals who carried out the colonoscopy at Weston General Hospital for her death. He also ruled out gross failings by nurses at NHS 111.
Dr Harrowing told the inquest: “Insofar as the nurses are concerned at Weston General... I do not find either individually or collectively that there was any gross failing on their part.
“I turned to involvement of the nurse from NHS 111. She gave evidence that she was aware of possibility of serious life-threatening effect of colonoscopy.
“The nurse made inquiries of Mr Longden and asked questions. I’ve heard evidence that she did not fully recognise red flags during questioning of Mr Longden.
“It is easy with hindsight to say she should have taken a different course of action. I have to consider whether that amounts to a gross failure.
“Even if she recognised it as a more serious condition, I do not consider that an ambulance would have arrived within time.
“I therefore do not find there was neglect for the care of Mrs Longden on this occasion.”
The cause of death was recorded as internal bleeding – an intra-abdominal haemorrhage – and a splenic injury as a result of the colonoscopy.
Following the inquest, Weston General Hospital and NHS 111 said a number of measures have been introduced to avoid complications Susan suffered in future cases.