A pensioner died after he was wrongly discharged from hospital, a sheriff has ruled.
Derek Cowan, 78, was admitted to Victoria Hospital in Kirkcaldy, after complaining about pain in his leg.
Mr Cowan, who suffered from a range of medical conditions including Alzheimer’s, epilepsy and high blood pressure, was kept in hospital for treatment and tests after being taken from his care home.
It was discovered he had an acute kidney injury but a communication failure led to him being discharged seven days later, on August 15 2019.
He was readmitted to the hospital four days later and was dehydrated and blood samples revealed an infection and “significantly raised” sodium levels.
He was seen by doctors who confirmed he was critically ill and offered palliative care before he passed away on August 23.
His partner, Linda Ballingall, later received an apology from NHS Fife after she made a formal complaint about his treatment.
Breakdown in communication
A fatal accident inquiry was held at Kirkcaldy Sheriff Court after it was decided his death gave rise to serious public concerns.
Sheriff Elizabeth McFarlane has ruled Mr Cowan should have remained in hospital for treatment and should not have been discharged.
She said the process of discharge was “defective” and there was a “lack of scrutiny” or review in the process of authorising his discharge.
The sheriff added there was a breakdown in communication between staff at the hospital and care home and aspects of his hospital care were substandard.
Mr Cowan should have been referred to a scheme known as Hospital@Home, which would have allowed blood samples to be taken and fluid levels monitored.
NHS bosses told the inquiry their practices had already changed in the aftermath of Mr Cowan’s death and no formal recommendations were made by the sheriff.
‘Discharge… led to untimely death’
In a written judgment, Sheriff McFarlane said: “Four clinicians were unable to give a comprehensive or cohesive account of who was ultimately responsible for Mr Cowan’s care or who was ultimately responsible for authorising his discharge.
“All of the evidence around the discharge process points to a process which lacked checks and balances, accountability and formality.
“This contributed to the discharge of a patient who was not fit for discharge and which ultimately led to his untimely death.
“The evidence about the lack of proper communication and a proper, robust system in place for the discharge of Mr Cowan is pretty overwhelming.
“There were so many areas of confusion that it is not surprising the system failed.”
The sheriff added: “Having determined that not discharging Mr Cowan on 15 August 2019 was a precaution that could have reasonably avoided his death, I have no difficulty in finding that these defects in the discharge process contributed to that wrongful discharge and therefore contributed to his death.”
NHS Fife apology
Dr Christopher McKenna, medical director with NHS Fife, said: “On behalf
of NHS Fife, I would like to apologise to Mr Cowan’s family and extend our
most sincere condolences to them.
“Sheriff McFarlane made no recommendations in her report, noting the board had already taken a number of actions to improve its discharge processes following an internal investigation.”
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