Husband died 36 hours after being sent from A&E without blood tests being checked

A devastated widow has called for lessons to be learned after her husband died from pneumonia 36 hours after being sent home from A&E.

Rob Walker was sent home from the emergency department at Sandwell General Hospital without a doctor reviewing blood tests that could have saved his life.

The 61-year-old from Tipton had been referred to the hospital in West Bromwich after he visited his GP complaining of difficulty breathing and a painful cough in November 2017.

A healthcare assistant carried out blood tests, but a consultant later discharged the 61-year-old without reviewing the results and prescribing antibiotics for a chest infection.

The father-of-one's condition continued to deteriorate and the following evening his wife, Maggie, dialled 999 and he was readmitted where he was diagnosed with respiratory failure. He died in the early hours of the following day, November 30.

Liability

Maggie then instructed medical negligence lawyers at Irwin Mitchell to investigate the care he received from Sandwell and West Birmingham Hospitals NHS Trust.

It then emerged the consultant who discharged him had not reviewed the results of the blood tests, which showed he had a severe infection.

Had the results been known, Rob 'would have more than likely been admitted', an internal hospital investigation found.

Medical staff had also not seen a letter from the GP referring Rob to hospital which included a working diagnosis he potentially had pneumonia or a blood clot in his lungs.

A subsequent inquest ruled Mr Walker being sent home without hospital staff checking his test results amounted to neglect.

The coroner wrote to the trust to raise his concerns and demand a review of the process for review of blood tests and ensuring referral letters are read.

The trust has since admitted liability and acknowledged that Rob having "received appropriate treatment would, on the balance of probabilities, have survived".

Dumbfounded

Maggie, 60, said: "The last few days of Rob’s life were terrible. He was so unlike himself. He struggled to breathe and could hardly speak. He was usually so fit and healthy.

“I was dumbfounded by the decision to let Rob go home but trusted the decision of a senior doctor.

"However, when he continued to get worse I knew he needed help.

"I could not comprehend what was happening when he was readmitted and placed in intensive care.

"To be told to say goodbye to my husband and lose him less than a minute later was a total shock – a day previously I had been told that he just had a chest infection."

Devastated

Mrs Walker added: “I have been left absolutely devastated by the loss of my husband, best friend and soul mate. Rob was one of life’s good guys. None of our family can believe he has gone.

“Every day is a challenge which is made worse by knowing that Rob would still be alive today if those who caring for him had just checked the blood tests.

“The consultant who discharged Rob seemed quite dismissive and I feel that he did not carry out a full investigation of Rob’s symptoms.

"He did not mention anything about the GP’s letter or blood tests and it was all very rushed. He only examined Rob’s chest when I asked him to.

“All we can hope for now is that Rob’s death is not in vain. Regardless of what pressures A&E staff may be under, it is vital that they take time to fully diagnose a patient’s condition. Rob’s death is a reminder of what can happen when they fail to.”

Serious incident investigation

David Carruthers, Sandwell and West Birmingham Hospitals NHS Trust's medical director, said: "We would like to extend our condolences to the family and friends of Robert Walker on their sad loss, and assure them that we have thoroughly investigated the circumstances surrounding Robert’s treatment, with the process being on our board’s publicly published risk register since early last year.

“Our serious incident investigation has led to improved practice relating to the way we ensure that test results are acknowledged, allowing for appropriate action to be taken.

"Within our emergency departments tests are documented within a system called Rapid Assessment & Treatment, which provides an opportunity to detail any investigations ordered.

"This section is now routinely used at triage to record when blood has been taken for testing to help support the clinical assessment and decision making that is undertaken by medical staff.

"The importance of this has been advised to all staff, through morning safety briefings and reminder posters in the triage rooms."