Coroner Finds Missed Opportunities To Diagnose Serious Heart Condition Led To Woman’s Death

Nelsons represented Mrs B to investigate a medical negligence claim against United Lincolnshire Hospitals NHS Trust (‘the Trust’) in relation to the death of her mother Mrs H following a hospital admission at Lincoln County Hospital just a few weeks earlier.

Background

Mrs H, who was described by her family as fit and well for her age, suddenly collapsed during a game of bowls in November 2019. She attended the Accident & Emergency Department at Lincoln County Hospital where she predominantly presented with a sudden onset of chest pain as well as a number of other concerning symptoms.

Despite presenting with eight of the recognised risk factors for aortic dissection, including an abnormal ECG result, this diagnosis was not investigated nor considered during Mrs H’s three-day admission. Doctors considered other possibilities such as acute kidney disease and musculoskeletal pain.

Mrs H was discharged home with a plan for her GP to review her blood pressure medication and to arrange a referral to the outpatient Cardiology department for a number of tests. Following her discharge, Mrs H’s health unfortunately deteriorated and she sadly passed away at home in December 2019 before the tests could take place.

It only came to light following Mrs H’s death that she sadly suffered from an aortic dissection – this is a tear in the inner layer of the aorta which is the large blood vessel of the heart. The overall cause of Mrs H’s death was haemopericardium (blood in the pericardial sac of the heart) which was caused by the untreated aortic dissection.

Inquest

The Coroner opened an inquest in order to investigate how Mrs H died and following the inquest hearing in February 2021, it was found that there were a number of missed opportunities to diagnose Mrs H’s condition during her inpatient admission, especially in light of the fact that she presented with the “typical symptoms and signs” of aortic dissection at the time.

The Coroner found that if the condition had been diagnosed correctly at the time, it is likely that Mrs H would have been referred to a regional cardiothoracic centre for emergency surgical repair and therefore survived.

Hospital investigation

The Trust also conducted its own internal investigation into Mrs H’s death and was forthcoming in identifying its failures in Mrs H’s care. The Trust acknowledged that the treatment Mrs H received at United Lincolnshire Hospital was inadequate and amounted to a breach of duty of care. The Trust admitted that Mrs H should not have been discharged home from the hospital and should have been kept in for further tests.

The investigation found that medical staff failed to use a screening assessment tool and other clinical tests to diagnose and treat aortic dissection and if those assessments were conducted at the time, it is likely on the balance of probabilities that Mrs H would have been diagnosed, treated and survived the condition.

The findings of this investigation identified a number of areas of improvement and planned for specific steps to be taken to reduce the risk of this error occurring again in the future. This includes arranging refresher training for clinical staff on the diagnosis and treatment of aortic dissection.

Settlement

Baishali Clayton (Senior Associate) and Shrdha Kapoor (Trainee Solicitor) in our Medical Negligence team assisted Mrs B in order to reach a settlement of the associated medical negligence claim.  In light of the critical findings, the claim was settled out of Court and for a five-figure settlement sum.

Although in this deeply distressing case financial compensation could not make up for the sudden and unexpected loss suffered by our client and her family, by going through the investigative process our client was able to get much-needed answers to her questions and also hold the Trust accountable for the mistakes made in her mother’s care and treatment.