Audrey Christine DAWS · Prevention of Future Deaths report

On 12 October 2012 I commenced an investigation into the death of Audrey Christine DAWS, then aged 84 years. The investigation concluded at the end of the inquest on 2 July 2014.

The cause of death was found to be:

1a Peritonitis and Bronchopneumonia;

1b Perforated Gastric Ulcer (Treated).

The conclusion of the inquest was that Mrs Daws died from Natural Causes to which Neglect contributed.

Mrs Daws was admitted to the Emergency Department at Derriford Hospital at 12.38 on Friday 5 October 2012. She complained of chest pain, a burning sensation and feeling clammy.

At 14.30 hours she was examined by a Junior Doctor ████████ who was concerned to exclude an acute coronary syndrome as a cause of her symptoms. She took a sample of blood so that Mrs Daws’ troponin levels could be checked. She did not order a chest X-ray.

████████ noted that Mrs Daws was tender in the upper abdomen. She admitted Mrs Daws into the Medical Assessment Unit.

At 18.15 hours Mrs Daws was examined again by another doctor ████████ in the MAU. She did not believe there was a cardiac cause to Mrs Daws’ symptoms but accepted that it was necessary to exclude this. She took a further sample of blood as the first one had broken down and was not suitable for testing.

She also ordered the patient’s old medical notes and records. She wanted to see if the left bundle branch block found on ECG had existed at the time of any earlier ECG.

████████ requested a chest X-ray.

At 19.04 hours Surgeon ████████████████ examined Mrs. Daws. In evidence he said that he would have expected an X-ray result to have been available within two to four hours of having been requested. It was not available at the time of his Ward round.

████████ and Surgeon ████████████████ completed their shifts and left the Hospital. The results of the X-ray were not to hand. Indeed, Mrs Daws had not been for X-ray at that time.

It was not clear what information in relation to Mrs Daws was conveyed to the doctors coming on to perform the night shift on the MAU. In her evidence ████████ said she would have expected to have told them that the results of the X-ray were still awaited. It appears as though nothing was done to chase the X-ray during the entire course of the night shift. Shortly after midnight, I understand that Mrs Daws was moved to a Ward in the Hospital. I heard no evidence as to what, if any, information was exchanged during the transfer.

At 11.19 hours on Saturday 6 October Mrs Daws underwent her chest X-ray.

She was reviewed by another junior doctor, ████████ approximately 10 minutes later. He checked the image system but the result was not then available.

In his evidence, ████████ said that he was not clear whether the X-ray still needed to be requested. The reason for his apparent confusion was that while his junior colleague, ████████ had suggested this when she saw Mrs Daws at 18.15 there was nothing in the notes from the Senior Review conducted by ████████ to indicate whether or not he confirmed this approach.

████████ appears not to have asked the patient whether she had gone for an X-ray and further appears not to have checked the position with any seniors on duty during the course of that shift.

A further point to come out of ████████ evidence was that he did not receive a formal handover in respect of Mrs Daws from the night shift.

████████ reviewed Mrs Daws at 16.49 the same day. She had presented as much improved but as she had vomited he decided that she should remain in Hospital for further observation.

████████ said that he did not then check the imaging system to see whether the results of any X-ray were to hand. He explained this by saying that he had asked nursing staff whether Mrs Daws had been off the Ward. When they told him she had not (incorrectly) he did not believe that it was necessary to look for the result of the X-ray.

No one from the night shift appears to have checked whether the results of the X-ray had come back.

On Sunday 7 October Mrs Daws suffered a fall. She was then examined by medical staff as her condition had deteriorated. It was only at approximately midday that the result of the X-ray was discovered. It showed air under the diaphragm indicating a perforation.

Subsequently, Mrs. Daws underwent surgery but her condition deteriorated and she died.

1. Handover of Information. The need for Mrs Daws to undergo a chest X-ray and for the result to be checked appears to have been lost as medical staff have changed at the end/start of consecutive shifts. You may wish to consider whether there needs to be a formal handover in respect of every patient where outstanding investigations are highlighted.

2. A chest X-ray should have been ordered at the time of Mrs Daws admission into the emergency department.

One was ordered approximately four hours later but it was not performed for nearly 17 hours. This was described as “inexplicable” during the Inquest hearing. It is plainly undesirable for an investigation that is considered urgent to be delayed for so long without anyone identifying the issue.

Related to this issue is that once the X-ray was performed, the result was not seen by medical staff for over 24 hours. No satisfactory explanation was put forward as to why this occurred.