Hospital missed ruptured spleen which led to man’s death

PATIENT DEATH ... the accident and emergency department of South Tyneside District Hospital.

PATIENT DEATH ... the accident and emergency department of South Tyneside District Hospital.

EMERGENCY doctors at a South Tyneside hospital failed to spot a man’s ruptured spleen which led to his death, an inquest heard.

Bruce Wardrop was taken to the accident and emergency department at South Tyneside District Hospital after falling down the stairs of his home in Rose Crescent, Whitburn.

The 68-year-old was suffering from shortness of breath and low blood pressure, but doctors did not realise he had fractured seven ribs and suffered a ruptured spleen – which led to him dying from an intra-abdominal haemorrhage.

He died in the hospital’s resuscitation room at 11.46pm on February 1, 2013 – less than three hours after the fall.

South Tyneside coroner, Terence Carney, found Mr Wardrop died of an undiagnosed condition which, if diagnosed, may not have cost his life.

South Tyneside NHS Foundation Trust says it accepts the finding.

Mr Carney said he had concerns over the handover of Mr Wardrop by paramedics to the hospital. He said there were not enough questions asked of the paramedics or enough appreciation of why Mr Wadrop’s blood pressure had dropped so low.

He said he was also worried about the prominence some doctors gave to the level of alcohol Mr Wardrop had consumed, and the fact that he was left in the care of just one doctor, despite the hospital being pre-alerted of his arrival.

He said: “The trust’s solicitor is directing me towards ruling this as an accidental death.

“My finding is that this man died as a consequence of an undiagnosed condition, which, if diagnosed, could have given rise to treatment which may have led to a different outcome.”

The severity of Mr Wardrop’s injuries and his ruptured spleen was only discovered at his post-mortem examination.

The inquest heard that Mr Wardrop had been at home with his wife, Brenda, on the night he died and had “a few” drinks before going to bed at 9pm, but was not intoxicated.

After hearing a noise, she found her husband at the bottom of the stairs and phoned for an ambulance.

Paramedic Luke Hunter said that his blood pressure dropped so much that he thought it was a false reading, and he asked the control room to pre-alert the hospital that they were on their way with Mr Wardrop.

Doctors and nursing staff were waiting for Mr Wardrop when he arrived and a chest X-ray revealed three rib fractures.

At one point, Mr Wardrop pulled out his cannula – which was being used to give him fluids – and while a doctor was trying to reinsert it, he collapsed.

Doctors attempted to resuscitate him, but he had suffered a cardiac arrest and died.

Home Office pathologist Dr Jennifer Bolton said an X-ray of Mr Wardrop at the hospital showed just three rib fractures, but that he had actually broken seven.

She said his spleen was torn in three places and his abdomen was filled with blood from it.

Dr Alan Rodgers, medical director of South Tyneside Foundation Trust, told the hearing Mr Wardrop’s case had since been reviewed and that he was surprised by the outcome of the post-mortem examination.

He said: “I don’t think anyone had a clue that this was a splenic rupture.”

After the hearing, Ian Frame, South Tyneside NHS Foundation Trust’s executive director of personnel and development, said: “We would like to extend our deepest condolences to the family of Mr Wardrop.

“His was a complex case involving a very uncommon condition and some unusual features, which made diagnosis particularly difficult.

“We accept the coroner’s findings and will use them to inform our future practice.”

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