Anne Whitworth · Prevention of Future Deaths report

On 30th October 2013 I commenced an investigation into the death of Anne Whitworth aged seventy-eight. The investigation concluded at the end of the inquest on 4th July 2014. The conclusion of the inquest was Anne Whitworth was a widowed lady aged seventy-eight years who had suffered with diarrhoea for two weeks. She saw her GP on 30th August 2013 regarding this, who arranged for her to see a gastroenterologist for further investigations. By 8th September 2013, Mrs Whitworth was suffering with constipation. She saw a doctor at the Local Care Direct Drop-In Centre when it was thought that she was constipated and a laxative was prescribed. Mrs Whitworth became acutely unwell later that day and was taken to St. James’s University Hospital, Leeds by ambulance where her death was confirmed at 2205 hours on 8th September 2013. A post mortem examination reveals the cause of her Intestinal Obstruction was a Volvulus of the Sigmoid Colon which was not identified at her previous GP and emergency appointment. I concluded that this to be a death from natural causes.

1. Mrs Whitworth had seen her own GP on 30th August 2013 complaining of a two week history of diarrhoea. Her GP was concerned about her symptoms and arranged a referral to a gastroenterologist for further investigation. This referral had not been achieved by the date of death.

2. Mrs Whitworth developed severe stomach pains and shortness of breath on or around 8th September 2013. She was taken by her son to a Local "Drop-In Doctor" and the attending doctor diagnosed a blockage in her bowel and prescribed medication and advised her to see her GP if her symptoms did not resolve.

3. Later that day her pain became considerably worse. An ambulance was called and Mrs Whitworth was taken to St. James’s University Hospital, Leeds at 2130 hours on 8th September 2013. Mrs Whitworth suffered a respiratory and cardiac arrest on route to hospital. Despite all efforts, her death was confirmed at 2205 hours on 8th September 2013.

4. A post mortem examination showed the cause of death to be

1(a) Aspiration of Gastric Contents due to (b) Intestinal Obstruction due to (c) Volvulus of Sigmoid Colon.

1. The Emergency Doctor stated that had he been aware of the GP consultation on 30th August 2013 and her then symptoms and the fact that a referral to a gastroenterologist had been made, his management of Mrs Whitworth would have been different.

2. He explained that out of hours he could not access Mrs Whitworth’s medical records. Their computer systems were not compatible and therefore he could not access her medical records electronically which is a major handicap to GPs working on urgent presentations out of hours.

3. The Out of Hours GP conceded that there was a missed opportunity to escalate Mrs Whitworth’s treatment options.