A care worker who died on her 47th birthday did not have her perforated bowel diagnosed for 22 hours after going to hospital, an inquest heard.
Elaine Hargreaves, of Orange Street, Accrington, was taken to Royal Blackburn Hospital with abdominal pain and assessed as ‘category orange’ – meaning she should be seen within one hour.
However Blackburn Coroners Court heard how there was a ‘delay’ and the grandmother-of-seven was not seen for around 90 minutes.
When examined, the doctor ‘had no reason to believe’ she was suffering from a perforated bowel as there were ‘no signs’, the hearing was told.
The inquest heard how Mrs Hargreaves had previously been diagnosed with alcoholic liver disease and suffered from a build up of fluid and a chest x-ray was ordered to check for infection.
However medical registrar Dr Michael Teng, who later examined the x-ray, said ‘in retrospect’ he failed to spot the signs of a perforated bowel.
When asked by coroner Michael Singleton to say why, he said: “Unfortunately I can’t and again I apologise to the family for missing that. It’s not something I was intending to pick up on a chest x-ray.”
The inquest heard how the perforated bowel was not diagnosed until 22 hours later by the speciality registrar and Mrs Hargreaves was taken to the intensive care unit to be ‘stabilised’.
Consultant surgeon Lyndon Jones told the inquest how he found six litres of fluid in her abdominal cavity ‘which looked infected and consistent with a perforation’.
Dr Jones said at the time the surgery was performed ‘it was more likely she would die than survive’ as she had ‘some serious pre-existing illnesses’. Mrs Hargreaves condition deteriorated after the surgery and she passed away on June 4.
Recording a verdict of death by natural causes, coroner Michael Singleton said that the it was impossible to say whether the delay had caused her death but it had reduced her ‘relatively small’ chance of survival.
Dr Ian Stanley, deputy medical director at East Lancashire Hospital Trust, said a ‘serious incident report and a route cause analysis report’ was ordered after her death which found ‘individual and not systematic failings’.
He told the hearing that ‘opportunities were missed’ and that the doctor who reviewed the x-ray had ‘misinterpreted’ air in her diaphragm which ‘led to delays in diagnosis and treatment for acute bowel perforation’.
But Dr Stanley said: “Had these measures been undertaken earlier it is unlikely the outcome would have been different in view of the patient’s pre-morbid state.”
The family of Elaine Hargreaves have blasted hospital bosses over her death.
Speaking after the inquest, her daughter Rebecca Hargreaves said: “It’s an absolute disgrace and it’s not fair. We have not got the outcome we wanted. She has been failed by the NHS.”
In a statement, Rebecca and her family said she was the ‘most beautiful lady’.
It added: “The pain I feel everyday is unbearable.
“She will never see us achieve, marry or even have more children.
“She met my daughter before her first birthday and died.
“Nothing will ever bring her back.
“Words can’t describe how much she is missed.
“We thought she was safe but died in the hands of the NHS failing her from the moment she arrived in A&E.
“Heaven has gained our mum and my dad’s wife and a great mum to the children. Miss her always.”
Dr Ian Stanley, Deputy Medical Director at East Lancashire Hospitals NHS Trust, said: “Our thoughts are with the family and friends of Mrs Hargreaves and we appreciate that this is a very difficult time for them.
“Following her death in June, a full investigation was carried out and we have fed back to the medical staff involved and shared the learning within the organisation.
“Mrs Hargreaves was very poorly when she arrived in A&E and the coroner accepted that not recognising the true diagnosis in the first hours of presentation sadly made no difference to the eventual outcome.”
