A grandmother was denied a potentially life-saving scan because her hospital had a policy of not routinely carrying out the procedure on weekends, a coroner has concluded.
Sandra Wood, 69, had been referred to Tunbridge Wells hospital at Pembury, Kent, on a Friday afternoon for emergency treatment after her GP suspected she had a dangerous bowel obstruction.
Doctors diagnosed her with a urinary tract infection and constipation but did not conduct a CT scan which would have identified how critically ill she was.
Instead, the mother-of-three, from Burham, Rochester, was told to return the following week because the hospital did not routinely arrange for a scan over the weekend unless it was urgent, her inquest was told. She collapsed at home hours later and was rushed to Maidstone Hospital on Saturday but died at around midday.
In a damning ruling, North West Kent Senior Coroner Roger Hatch said that delays in diagnosing her condition were “critical”.
He found that doctors should have realised the seriousness of Mrs Wood’s condition when she arrived at A&E on Friday 17 April, last year, admitted her and arranged for a CT scan “as a matter of urgency”.
Mr Hatch said: “Arrangements should have been put in hand for the CT scan to have been carried out on the 17th/18th April 2015 due to the emergency situation that had occurred this was clear from the medical history and then current complaints of Sandra.
“It is highly unsatisfactory that facilities for the CT scan to be carried out at the weekend at Tunbridge Wells hospital [Pembury] are not routinely available without having to go through a number of steps for this to be arranged. In this case, the delay until the Monday was critical as the outcome has sadly demonstrated.
Following a day-long inquest in Gravesend, Kent, last month, Mr Hatch recorded the death as due to natural causes “as a consequence of the failure by the Tunbridge Wells hospital [Pembury] to correctly diagnose and treat” Mrs Wood when she arrived at A&E.
He gave Maidstone and Tunbridge Wells NHS Trust 56 days to set out what steps it will take to prevent future deaths given the concern and risk to other patients.
Mrs Wood’s family fear that without immediate action other patients might die unnecessarily.
In a statement, Mrs Wood’s daughter Amanda Sparkes said: “The coroner has now confirmed what we always suspected; the hospital’s policy not to carry out a scan caused this tragedy.
“It is devastating to think that had my mum been given the treatment she deserved she would have survived.
“It adds to our grief that had we not fought for answers and an inquest, we suspect this would have been put down as just another unfortunate death and there would have been no pressure to find out what went wrong.
“It’s too late for us, but we believe anybody else could go into that hospital and get the same poor level of treatment. That’s totally unacceptable. Lessons must be learnt, the trust must accept the coroner’s recommendations and do everything in its power to stop this from happening again.”
The family has launched civil action against the hospital over the failures identified in Mrs Wood’s care.
Tim Deeming, a clinical negligence specialist lawyer at Slater and Gordon, who represents the family, said: “This case illustrates of how a policy can have a tragic outcome and the coroner has demanded urgent action to prevent future deaths.
“It has been extremely distressing for Mrs Wood’s family to sit through this inquest and to repeat how she was so badly let down in her most desperate hours of need.
“The coroner’s findings are critical, both with regards to the policy for scanning and turning Mrs Wood away at midnight on a Friday.
“The GPs had referred Mrs Wood having diagnosed suspected bowel complications and the coroner is clear that she should have been admitted to Pembury hospital and an urgent CT scan carried out, rather than discharging her with a diagnosis of a UTI.
“This tragedy must be a catalyst for improvements so that processes are put in place - both at the trust, and across the NHS - to prevent a similar incident happening to another family.”