Sylvia Scully · Prevention of Future Deaths report

On 20th February 2020, Alison Mutch OBE, Senior Coroner for Greater Manchester South, opened an inquest into the death of Sylvia Scully who died at Tameside General Hospital, Ashton under Lyne on 10th February 2020, aged 86 years. The investigation concluded at the end of the inquest, which I heard on 20th and 28th July 2020.

The court heard evidence that Mrs Scully died as a consequence of:-

1a) Intra-Abdominal Sepsis;
1b) Hollow Viscus Perforation;
III) Frailty, Ischaemic Heart Disease.

The inquest concluded with a Narrative conclusion to the effect that Mrs Scully died as a consequence of a hollow viscus perforation which was first formally diagnosed over 10 hours after she attended hospital complaining of abdominal pain and vomiting. By the time this diagnosis was made, Mrs Scully's condition had deteriorated to such an extent that she was too unwell to withstand emergency surgery. Mrs Scully's death was contributed to by neglect.

On 9th February 2020, Mrs Scully became unwell with sudden onset abdominal pain and vomiting. She was taken to Tameside General Hospital Emergency Department, arriving at about 12:30. Following triage and at about 14:30, Mrs Scully was first seen by a junior doctor who arranged tests and examined her, recording findings of tenderness and guarding. Despite this, Mrs Scully's medical history and an abnormal venous blood gas result, she was not referred to the surgeons until around 16:18 by which stage other investigation results were available.

When reviewed by the surgeons, a management plan was arrived at which included an urgent CT scan intended to provide a definitive diagnosis as to the cause of her acute abdomen.

The consultant radiologist reported another patient's scan in error. This error was ultimately appreciated and a correct report issued, revealing a hollow viscus perforation. By this time however, Mrs Scully's condition had deteriorated to such an extent that she was too unwell to withstand emergency surgery.

Mrs Scully died in hospital on 10th February 2020 as a consequence of complications of a hollow viscus perforation.

1. The court heard evidence that the Consultant Radiologist on-call for the Trust and reporting on urgent out-of-hours imaging from home, had more limited remote access to relevant systems than radiologists working for remote reporting companies and had been provided with less equipment than such an individual. Given the importance of effective out-of-hours reporting of imaging to emergency care, it is considered authoritative guidelines as to requisite access and recommended equipment could assist in reducing such variations.

1. Notwithstanding the circumstances of Mrs Scully’s death, the Trust’s routine clinical governance processes have not resulted in a formal Serious Untoward Incident investigation or similar taking place in respect of the care and treatment provided to her. This is a matter of concern given the great importance to patient safety of robust and effective investigations being undertaken in a timely fashion;

2. A Rapid Assessment and Treatment Model was not in use at the Trust’s Emergency Department at the time of Mrs Scully’s attendance in respect of ‘walk-in’ patients. Such a paradigm would have seen Mrs Scully assessed early on by a senior doctor who had the experience and authority to promptly initiate all relevant investigations (including ordering CT Scans) and commence treatment, in advance of review by the surgical team.