Missed hernia led to mum-of-four's death
A woman died at home after three doctors failed to notice she had a hernia.
Hull Coroners' Court heard Elizabeth Sarah Smith, 34, of Whitehope Close, Bransholme, died on April 8 after she was twice discharged from Hull Royal Infirmary on April 5 and 6.
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Hull Royal Infirmary.
The mother-of-four had gone to accident and emergency on both occasions complaining of severe pain in her abdomen and vomiting.
However, three doctors failed to notice she had a hernia, despite it having been diagnosed on April 3 by a nurse practitioner at her GP's surgery.
Instead, they diagnosed her as having constipation and sent her home with medication.
Mrs Smith died from peritonitis - a huge infection of the body - after the untreated hernia ruptured.
The court heard written evidence from two independent experts, which concluded she had received substandard care on each occasion.
Dr Francis Morris, a clinical director in emergency medicine with 23 years experience, said to check the groins of a patient with Ms Smith's symptoms for hernias during an abdominal examination was "standard practice".
However, not one of the three doctors who examined her had recorded in their notes whether they had examined the groins.
The experts concluded Mrs Smith would not have died if the hernia had been spotted.
Speaking to the court, her husband Simon Smith said he had told medical staff treating his wife she had been previously diagnosed with a hernia.
The court also heard the first nurse to assess Mrs Smith when she attended hospital had made a note of a possible hernia.
However, all three of the doctors who later examined her said they did not recall being told she had been previously diagnosed with the hernia.
Hull and East Yorkshire Hospitals NHS Trust has launched an internal investigation into Mrs Smith's death.
Her family are also taking legal action against the trust.
Coroner Geoffrey Saul returned a narrative verdict, in which he summarised the evidence given throughout the inquest.
He said: "Elizabeth Sarah Smith died at home on April 8 from peritonitis, as a result of a ruptured incarcerated inguinal hernia.
"The presence of the hernia was not identified on examination at hospital on April 5 and 6.
"If it had been identified on either of those dates, it is likely that surgical intervention would have followed prior to the development of peritonitis and, with such intervention, there is a likelihood that Elizabeth Smith would have survived."
Adrienne D'Arcy, acting on behalf of Hull and East Yorkshire Hospitals NHS Trust, said: "The expert opinion will be fed back to the trust, whose investigation into this incident is continuing.
"The trust wants to establish the root cause and learn lessons from this case."
The trust said it could not comment further as legal proceedings are now active.
34 Comments
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by steve collins, woodmansey
Saturday, October 17 2009, 5:35AM
“end of april 2008 i was rushed into hri and was operated on for a ruptured bowel within 3 hours of being admitted i was resusitated twice had a temporary colostomy which was reversed in nov 2008 i can not speak highly enough of the way i was treated and i would not be alive now but for the quality and speed of treatment”
by roger147, hull
Tuesday, October 06 2009, 7:49PM
“my mother was admited after a fall and hitting her head very little action was taken despite our given information of the severity of the head impact on falling. she was discharged with a pamphlet of possible problems. She was readdmitted 3 days later and sadly died 4 days later of a massive haemorage which was on going since the fall.An inquest was held but no one was deemed responsible,but it was noted information given by myself was not passed on.You go into HRI at your own peril and too often never leave.Roger147”
by anon, hull
Tuesday, October 06 2009, 4:09PM
“hri resutation dept. /ward 90 could not have been more efficient or kinder to my partner and i, he died wiithin 3 hours of arriving by ambulance..our gp.diagnosed a bug. 12 hours earlier, if you dont fewel any better come back in 3 days. he colapsed with a heart attack within hours. . when i rang to inform the surgery he said he did not complain of any pains in his arms or chest just felt generaly unwell. gp gave him a bottle of gaviscon and co codamol.”
by Emma, Hull
Monday, October 05 2009, 6:23PM
“When will these doctors and nurses take notice...I nearly lost my daughter at the age of two through the incompetence of the staff of Hull Royal.After taking my girl to casualty with abdominal pain and sickness I was told it was a viral infection,8 more visits throughout the week(even being called a neurotic mother)they finally took an x-ray which certainly shook them up...My daughter had burst appendix which had caused absesses on her ovary and intestines.Six hours of surgery,blood transfusions and totally comatose on morphine for days.Septicemia had set in and we were told that she was only hours away from death.I thank God everyday that she pulled through..but if it was left up to the medical staff at HRI she would'nt be here today.If you know something is not right then I strongly urge you to push for better care and attention, do not let them fob you off.My heartfelt sympathy goes out to Elizabeth's family.”
by lesley, hull
Monday, October 05 2009, 3:27PM
“This story does not suprise me.I hope the doctors involved are sacked and not allowed to work in any hospital again,but it wont happen will it!!!”
by Bimty, Right here
Monday, October 05 2009, 8:30AM
“Jamie, Hull what an utterly thoughtless comment to post - telling people to "get over it". Could you just "get over" losing a loved one knowing there was severe negligence involved and that their life could have been saved? Don't be so ridiculous. I do agree that a lot of people (not most as you put it) perhaps haven't contributed through NI payments but we are lucky to live in a country that does provide free healthcare and sadly whether you like it or not that means everyone is entitled to it.
I am really saddened to read this story. I have my own similar story but I won't go into detail but I do wish we had taken legal action now but at the time it was just too devastating getting over the death of a loved one. I've had visits to A&E before and have also been made to feel like you're wasting their time. I won't tarnish all doctors and nurses with the same brush as there are some brilliant, hard working and selfless ones out there, just sadly there appears to be a great deal of doctors who just don't seem to give the patient care they are employed/paid to do. Very sad, sympathies to the family and all the others x”
by valueadded, Thorn
Monday, October 05 2009, 7:47AM
“My experience of HRI is that no matter what is wrong with you, if you are not happy with the diagnosis and treatment .... make sure you don't leave or take what they tell you unless you are completely satisfied. It's not good to think like that but if you let them treat you how they want to, you are in and out with a batch of painkillers only then to be re-admitted days later with a more serious condition. Don't let them convince you otherwise. you know your own body and your lobved ones, if something isn't right ... if you are able to ... then speak up and say.”
by Nancy Blake, West Hull
Sunday, October 04 2009, 11:17PM
“The theme repeated throughout is that doctors don't listen to patients and relatives, yet they are the ones who have the information doctors need to make accurate diagnoses. There may also be a hint in the patient's address - middle class people generally get more respect. My friend's mother died recently, about 36 hours after an emergency doctor told us it was 'a social problem', and to take her to a memory clinic. She had all the symptoms of congestive heart failure - swollen legs, arms and hands, a cough without a fever, but the doctor only listened to her stethescope. Her neighbour and friend made the diagnosis: 'That's what my aunt went like just before she died of heart trouble.' But we were in a North Hull Council property, so what did we know!”
by rainey, beside the sea
Sunday, October 04 2009, 10:16PM
“James, Hull.
Not being awful, but maybe if you had a choice would you rather be misdiagnosed by one of the bad doctors?”
by Amanda, Hull
Sunday, October 04 2009, 9:19PM
“It hurts to read this story and to see also that so many others have experienced the same. My mum went to A&E and was discharged also and sent home with a box of co codamol even thought she colapsed in front of an A&E nurse when she was discharged, dad took her home in a taxi and her condition worsened, we took her back to A&E 36 hours later where she was finally diagnosed with a perforated bowel, was rushed down to sugery and never woke up. We had to turn off her life support machine shortly after. When will they ever learn, how many more people have to die!!”