The death of a Fife mother in hospital could have been avoided at various stages in her care, a fatal accident inquiry has determined.
Linda Allan, 59, was admitted to Victoria Hospital in Kirkcaldy with a broken leg after a fall in her garden on October 15 2019.
She never left and died on October 23 – six days after an operation – when a stomach ulcer burst, causing bleeding into her bowel and multiple organ failure.
Her family claimed her treatment was “dangerously incompetent” and a fatal accident inquiry was held.
It took place at Dunfermline Sheriff Court before Sheriff Susan Duff in December and January.
The sheriff’s written judgement – not yet made public but seen by The Courier – states her death could have been avoided.
Chances to avert tragedy
The inquiry heard Ms Allan deteriorated quickly and she gave a pain score to staff of 10 – the highest – on October 19.
She 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.
Consultant orthopaedic surgeon Paul Jenkins told the inquiry a medical review should have been carried out at that stage.
Sheriff Duff’s ruling agreed.
She wrote: “Had MS Allan been the subject of daily reviews including a review of her medication on 19 and 20 October 2019, there were opportunities to detect the deterioration in her condition and to take action to prevent her further decline.
“Further, when Ms Allan’s pain score went from 0 to 10 over the period of just under seven hours on 19 October 2019, she should have been the subject of escalation to an urgent medical review at that stage which could have resulted in her condition being assessed and action taken to prevent further decline.
“Had Ms Allan been escalated to an urgent medical review on 20 October 2019 at around 1800 hours then she was seen by the Advanced Nurse Practitioner (ANP) her condition could have been assessed and action then take to prevent further decline.
“Any of those precautions might realistically have resulted in the death being avoided.”
Recommendations
Sheriff Duff said record keeping and documenting of Ms Allan’s condition was “inadequate”.
She said the boarding policy which saw the ward move “was not adhered to resulting in Ms Allan being boarded without her vital signs being taken.”
She recommended various procedures be reviewed and refresher training be periodically completed – specifically regarding boarding and escalation – to avoid future lapses.
The lead trauma surgeon should continue to review a random selection of records monthly.
The sheriff concluded: “The inquiry has established that the care which Ms Allan received post-operatively was not at the standard that would have been expected.
“There were opportunities for her condition to be reviewed which could have altered the tragic outcome of this case.
“I offer my most sincere condolences to Ms Allan’s family.”
Family’s conviction something went wrong
The inquiry was attended by Ms Allan’s daughters Sharon and Shona Adams, her partner Jamie Duff and other family.
They released a statement last night welcoming Sheriff Duff’s findings.
“We were hoping to see confirmation of reviews needed across pain management, medication and training of staff and we feel that we have that in today’s determination.
“What was additionally positive for us was to see the sheriff noting the care our mum was not at the expected standard and that if it had been, our mum’s death could have been avoided.
“We hope health boards all over Scotland take on board what has been unearthed at NHS Fife to make sure everyone is safe.
“Although we welcome the findings today, it should never have got to an FAI in the first place.
“From the beginning we’ve always felt something has been drastically wrong and this FAI has been vital in making sure improvements can be made to the NHS so people get the care they deserve.
“We’ve always had the conviction that what we’re doing is right and today we have that confirmed.
“It doesn’t matter if it involved the NHS or someone else – no one is above the law and mistakes need to be accounted for.”
A spokesman for NHS Fife said: “NHS Fife wishes to extend its condolences to Ms Allan’s family.
“We have just received the determination from Sheriff Susan Duff and will consider fully the sheriff’s findings and recommendations.”
