Mildred CLARK · Prevention of Future Deaths report

On 29th December 2017 an investigation was commenced into the death of Mildred CLARK. The investigation concluded at the end of the inquest 7th March 2019. The conclusion of the inquest was Died at 15:10 on 17th December 2017 at hospital following infection and failure of bypass graft to provide blood supply to the leg and haemorrhage that was incompatible with life. Delay in diagnosing the infection and haematoma on 16th December meant medical intervention options were limited.

Conclusion Narrative

1a Bilateral Acute Lower Limb Ischaemia
b Occluded Femoral Bypass Graft
c Haemorrhage from Infected Graft Left Groin
II Ischaemic Heart Disease

Patient presented with a mass in the groin and ambulance called. Eventually diagnosed following significant delay at William Harvey Hospital as failure of previous bypass surgery grafts. She was transferred by Kent & Canterbury surgery was performed and despite being able to stop the bleeding, it was not possible to restore good flow to the leg because of infection in the graft and delaying in treating the ischemia. There was significant delay in recognising the bleeding due to the failed bypass grafts and resulting ischemic limb meaning options for medical intervention were limited.
The only option was palliative. Previous surgery- aortic femoral bypass for aneurysm. Bypass for ischaemic right leg had been performed, most recently in August this year. Unfortunately, on this occasion it was not possible to re-vascularise the legs which were already ischaemic beyond repair (on the right) and made ischemic by arterial ligation (on the left) to control the bleeding.

Although this matter did not contribute to this death a concern was raised that a paramedic sought telephone advice from a hospital doctor by telephone on presenting symptoms and the initial diagnosis was that of a hernia were was extreme pain. The paramedic was instructed to carry out a procedure to reduce the hernia despite being informed that the paramedic was not trained to do so. The attempt caused extreme pain and failed.

(1) A senior member of ambulance crew gave evidence that reducing a hernia was not the role of a paramedic and a doctor should not instruct a paramedic to carry out this procedure particularly when they have stated they are not trained.
(2) A consultant surgeon gave evidence that:
a. a suspected hernia is not a medical emergency and there was no pressing requirement to undertake the procedure that could lead to complications if incorrectly carried out
b. where there is pain, swelling and hardness as in this case, if a hernia is suspected it would be reasonable to consider if this was a case of strangulated hernia as this could be a medical emergency and an attempt to reduce it cause significant complications and a patient should be taken to hospital
(3) There was a concern raised that staff may have felt pressured to act to avoid hospital admission during a period of winter pressure