A leading surgeon has concluded there were “serious deficiencies” in the care of Kirkcaldy woman Linda Allan, who died following an operation in the town’s hospital.
Consultant orthopaedic surgeon Paul Jenkins told the inquiry into her death a medical review should have taken place when she gave a pain score of 10 out of 10 on the evening of October 19 2019 – four days before she passed away.
Ms Allan, 59, was admitted to Victoria Hospital in Kirkcaldy with a broken leg after a fall in her garden on October 15.
She died on October 23 – six days after an operation – after a stomach ulcer burst, causing bleeding into her bowel and multiple organ failure.
Her family has claimed her treatment was “dangerously incompetent”.
A Significant Adverse Event Review (SAER) was carried out by NHS Fife in March 2020 and suggested the bleed may have been caused, at least partly, by an anti-inflammatory drug.
‘Serious deficiencies’ in care
A fatal accident inquiry (FAI) at Dunfermline Sheriff Court heard Ms Allan was initially treated on ward 33 but was “boarded out” to ward 10 – a nurse-led ward to get patients ready for discharge – to free up space for new patients.
The inquiry resumed on Wednesday with the focus on a report by Mr Jenkins.
Fiscal depute Alan Morrison read from the report’s conclusion, which said: “There were serious deficiencies in the care of Linda Allan.
“Medical review in advance of boarding to an area with no medical cover is likely to result in earliest detection and intervention on deterioration.”
Another part of Mr Jenkins’ report said the post-operative medical review was “inadequate” and recording of observations was “scant”.
Giving evidence, Mr Jenkins said he would have expected medication to be reviewed more than once a day if there were signs of instability in the patient.
He did not see any evidence of Ms Allan’s medication being reviewed.
Medical review not carried out
His report suggested diagnoses other than constipation should have been considered as it was significant Ms Allan presented a pain score of 10 out of 10.
Asked by the fiscal depute about the significance of having no medical review at that point, Mr Jenkins said: “There had to be a medical review either that evening when her pain was 10 out of 10 or during the following day, prior to the transfer to ward 10.
“It is possible a deterioration might have been detected… there could have been a decision not to transfer or a decision to instead (make) future investigations such as checking of blood or ordering an x-ray of the chest or abdomen”.
The inquiry heard Mr Jenkins’ report suggested, had observations been performed prior to the ward transfer, it is likely low oxygen saturations would have been detected.
He said this should have prompted a more urgent review, including a chest x-ray, which might have revealed air under the diaphragm resulting from a perforation, or a hole in the abdominal area.
He said: “If that happened there would have been an immediate referral to a general surgeon team, also likely involvement of the intensive care team and a decision made to proceed to surgery for laparotomy in exploration of the abdomen at an earlier point”.
A laparotomy is an exploratory stomach operation.
Early laparotomy may have helped
The Advocate representing the NHS, Elaine Russell, told the inquiry when Ms Allan’s pain score of 10 was given, it was not stated where in the body that pain was coming from.
Ms Russell also highlighted an advanced nurse practitioner carried out an abdominal examination and noted it was not tender, which Mr Jenkins said was unusual.
Ms Russell asked Mr Jenkins whether an earlier laparotomy would have meant a different outcome for Ms Allan.
He replied: “It depends on timing but on the balance of probability, I think it would.”
Inquiry continues
An FAI can be held when a death is sudden, suspicious, unexpected, accidental or unexplained or which have occurred in circumstances that may give rise to public concern.
The inquiry, before Sheriff Susan Duff, is expected to conclude this week.
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