Market Drayton man, 27, died eight days after being discharged from hospital

Declan James Dunne, who was known as Decky, died from septic shock caused by peritonitis, a hearing in Shrewsbury was told.

Mr Dunne, 27, of Kings Avenue, Market Drayton, started feeling ill on December 20 last year and died at the Royal Shrewsbury Hospital on December 28.

His girlfriend Leighellen Evans said Mr Dunne arrived at the house complaining of stomach pain and being sick on December 20. She rang out-of-hours service Shropdoc and made an appointment but he worsened and the family called an ambulance.

His mother, Lisa Dunne, told Shropshire coroner John Ellery that when she arrived to look after the couple’s two daughters, ‘Decky’ was lying on the landing floor crying in pain.

Mr Dunne was taken by ambulance to Royal Shrewsbury Hospital where, Miss Evans said, they had a long wait before seeing anyone.

Mr Dunne was put on a fluid drip. He was discharged the next day with suspected food poisoning and told to take paracetamol and drink fluids, his mother said.

Miss Evans said in the following days Mr Dunne lay down most of the time and had no energy to get up and play with his daughters which wasn’t like him.

She rang the hospital on December 22 but said: “I was told to go through Shropdoc as they would not see him again.”

Calls to both Shropdoc and the NHS 111 service led to advice to take anti-sickness tablets and Nytol to help him sleep, she said.

In a statement to the inquest, his mother said her son was still ill on Christmas Day and despite taking strong laxatives, he could not go to the toilet.

“He apologised for not being able to get out and get Christmas presents for us,” she said.

Exhausted

The inquest heard from Miss Evans that Mr Dunne continued to be sick, day and night.

“He was exhausted and unable to sleep and was bloated,” she said.

She said on December 28 Mr Dunne started screaming her name.

“He said his lips and his arm were numb. I called 999. By the time the ambulance arrived his breath was rattling.”

He suffered a heart attack and was taken to hospital where he was taken to intensive care but died. A post mortem showed Mr Dunne died from septic shock caused by peritonitis caused by a twisted bowel.

The post mortem said it was a rare condition but if caught early, particularly in younger people there was a good chance of a good outcome.

Mr Subramanian Kumaran, consultant and clinical director at the RSH, who discharged Mr Dunne on December 21, said the patient had expressed a wish to go home as his symptoms were settling.

“The patient looked well and blood tests were normal,” he said.

He told the inquest that he had discharged Mr Dunne with suspected gastritis and said he had been told to come back if his symptoms worsened.”

The inquest continues.

Doctors ‘did not suspect’ twisted bowel

Three Shropdoc doctors, who saw Declan Dunne in the days leading up to his death, told his inquest they did not suspect a twisted bowel or obstruction.

Dr Jonathan Ashley, Dr Rebecca Chamota and Dr Marwan Al-Nasiri gave evidence to coroner John Ellery.

Dr Chamota, a recently qualified GP, broke down in tears as she gave evidence and said the death of Mr Dunne had so ‘destabilised’ her that she had only done one shift for the service since.

Both doctors said when examining Mr Dunne he had none of the abdominal symptoms that would have suggested a bowel twisting or obstruction. Dr Ashley, who saw him on December 22, said Shropdoc did not have access to records from either the hospital or West Midlands Ambulance.

He said the patient seemed to move quite easily and was able to climb onto the examination couch. Giving her evidence, Dr Chamota said Mr Dunne told her he had been vomiting and hadn’t slept for four days and had developed hiccups. He asked for sleeping pills saying he just needed to sleep, she said.

Rare

The coroner asked Dr Chamota if she had realised that this was the third time in as many days that Mr Dunne had sought help when she saw him on December 23.

She said she had not looked as his previous Shropdoc attendance and had not realised he had been taken to A&E by paramedics and then seen Shropdoc in previous days.

“I went on speaking to the patient in front of me,” she said. “It was winter and viral gastritis is very common in winter.”

She said Mr Dunne had not presented as someone with a bowel obstruction and this was an incredibly rare and complex case.

Because Mr Dunne had asked for sleeping tablets she asked her supervising GP Dr Marwan Al-Nasiri to review Mr Dunne, she said. Dr Al-Nasiri said he had been happy with her dealing with Mr Dunne. However he said he had not realised that the patient had an overnight stay at A&E or saw another Shropdoc doctor in previous days.

Sharing issue was identified

There is not enough sharing of patient information between different health services, a senior Shropshire consultant has said.

Stuart Thompson headed the root cause analysis investigation into the death of Declan Dunne at Princess Royal Hospital on December 28.

Giving evidence at his inquest, which is being held at the Shirehall in Shrewsbury this week, Mr Thompson said the investigation looked at the series of events leading up to Mr Dunne’s death to prevent the risk of such an incident happening again in the future.

He said in his experience it was best practice to stress to patients that if things did deteriorate they should come back to hospital.

On Mr Dunne’s visit to A&E on December 20 he said: “The department was fully staffed but it was very, very busy at the time.”

Staff, he said, had been reminded to tell patients this and he said posters are being pinned up in both the Royal Shrewsbury and Princess Royal Hospitals giving information that patients should contact the hospital again if their condition worsens.

He said: “In Shrewsbury the signage is up, in Telford it is only in minor injuries but we will ensure posters are put in prominent positions elsewhere.”

Coroner, Mr John Ellery, asked if there had been an ability for the ambulance service, Shropdoc and the Shropshire and Telford Hospital NHS Trust, all of which were involved in treating Mr Dunne, to share information about him to each other.

Mr Thompson said the mechanics for sharing information between parties and getting access to records were lacking. “It is a national problem because of patient confidentiality and data protection,” he said. “It is being addressed by the electronic patient records system but this is in its infancy.”