Early referral could have avoided grandmother's death, says coroner
A grandmother died two days after being sent home from the Royal Shrewsbury Hospital following surgery to remove her gall bladder, an inquest heard.
The death of 70-year-old Sandra Blue could have been prevented if she had been referred to hospital for her condition sooner, according to coroner Mr John Ellery.
But he said the decision by staff at the hospital to send Mrs Blue home after her operation was the correct one.
Mrs Blue, from Llanymynech, had been in pain for some time before her gall bladder was removed, the inquest at Shirehall heard.
She was discharged the following day but then suffered abdominal pain and sickness.
Mrs Blue was visited at home by Dr Waseem Aslam, a GP at Welshpool Medical Practice, who prescribed her antibiotics for a water and chest infection. But Mrs Blue deteriorated and died at the hospital the next day.
Dr Aslam apologised to Mrs Blue's family as he gave evidence. He said: "I saw her in her bedroom. She was mentally alert and had a fast pulse. I felt her tummy and it was soft with no signs of hardness.
"There was a sign of infection in the lungs. She said she had discomfort passing urine.
"I asked her to produce a water sample but she could not – her friend later brought me one to the surgery."
Dr Aslam said he diagnosed Mrs Blue as having a water and chest infection and prescribed antibiotics, which Mrs Blue's friend picked up.
The doctor said: "In the way things happened I did not get a chance to speak directly with Mrs Blue and I should have laid down specific details of what to do if her symptoms got worst or did not improve.
"I do feel I have let myself down on that and apologise to the family.
"In hindsight I should have been more specific about the time frame and symptoms."
The hearing also heard from Mr John Loye, consultant surgeon at the Royal Shrewsbury Hospital, who said the gall bladder operation had been a "standard uncomplicated procedure".
Mr Ellery, recording a narrative verdict, said: "Mrs Blue died as a complication of surgery but the family are saying had there been an earlier referral to hospital it may not have happened.
"There is evidence to suggest an opportunity for review may have been lost. I don't believe there is any criticism by the hospital discharge. It was appropriate.
"Dr Aslam should have told Mrs Blue that if she wasn't better in four to six hours she should have sought a medical review. It could have led to admission or treatment. If a 999 call was made earlier it may have changed a grim and unsurvivable condition to a survivable condition."
