Mr Zawdie Qounseye Bascom · Prevention of Future Deaths report

On the 8th September 2015 I opened an inquest into the death of Mr Zawdie Qounseye Bascom. The investigation concluded at the end of the inquest on the 17th June 2016. The conclusion of the inquest was natural causes contributed to by neglect.

Mr Bascom was a 38 year old gentleman who suffered an onset of severe abdominal pain on Saturday 10th May 2014. He presented to A&E at Newham General Hospital with the primary presenting complaint of severe pain and was assessed by a triage nurse and then a locum SHO. The SHO carried out an abdominal examination which revealed a non-distended, hard and rigid abdomen. Observations were noted to be within normal limits, as was a full blood count. Venous blood gases however revealed a low pH (7.217) and a raised lactate (2.2). Only one pain score was recorded during the course of the 5 hour attendance to A&E, despite the reason for attendance being severe pain. Mr Bascom was discharged from hospital with a presumed diagnosis of gastritis. Mr Bascom remained in severe pain throughout the 11th May 2014 and presented to his GP on the 12th May 2014. The GP was provided with a discharge summary from A&E, which included reference to no raised inflammatory markers and a normal chest x-ray. The GP was not informed of the abnormal venous blood gas results. The GP changed the prescription of lansoprazole to omeprazole and reassured Mr Bascom should return to A&E if the pain persisted or if he had no relief to the medication given. Mr Bascom collapsed at around 21:00 hours on the 12th May 2014 and in spite advance life support by paramedics and in hospital, he passed away on the evening of 12th May 2014 at Newham University Hospital. A post mortem examination confirmed a cause of death of 1a) Peritonitis 1b) Rupture of Inflamed Vermiform Appendix.

1) Mr Bascom presented in severe pain to A&E. This was his primary presenting problem. Despite this, there was no recording of his pain score on triage into A&E.

2) Analgesic medication was administered at 03:45 and a pain score recorded at 05:15 of 9/10. The doctor who recorded the pain score at that time could not recall whether he had any regard to the fact that analgesia had been given, when he noted the score of 9/10.

3) Further analgesia in the form of tramadol was given at 05:30. There was no further pain score recorded following this analgesia. No pain score was recorded prior to discharge.

4) On the basis of the evidence heard I found that Mr Bascom’s pain was not relieved prior to discharge. There was no documentation at all to support pain relief and ████████ confirmed that Mr Bascom continued to require support as a result of the pain, when he left the hospital. The independent expert gave evidence that the severe pain reported by Mr Bascom would be unusual in a case of gastritis.

5) It was noted in evidence that the Trust carries out pain audits in compliance with the College of Emergency Medicine. The consultant who gave evidence was unable to comment upon the practice at Newham University Hospital. The updated action plan referred only to regular audits in relation to sickle cell, fractured hip, and pain in children. The updated action plan does not address the circumstances where patients present to A&E in severe pain.

6) No pain score was recorded by any member of the nursing team. There was no evidence of any systematic assessment of pain (for example, response to analgesia).