Gross Failure By Two Sets Of NHS Staff Led To Woman’s Death

A woman suffering from a perforated duodenal ulcer died as a result of a gross failure to provide basic medical attention by NHS staff on two separate occasions, an inquest ruled yesterday.

Alison Christian, 36, died just before Christmas 2005 at the Northern general hospital, Sheffield. The inquest found that her condition was not recognised “until she was beyond help”.

Ms Christian collapsed at home on December 19 and was taken to the hospital. The “entirely reasonable diagnosis” was that she had a chest infection with muscular-skeletal pain. She returned to the accident and emergency department the next day with abdominal pain and other symptoms.

“Notwithstanding this, Ms Christian’s abdomen was not examined, nor was a blood pressure taken,” said Christopher Dorries, coroner for south Yorkshire west. “An examination of the abdomen would more likely than not have shown signs warranting further investigation such as tenderness or perhaps rigidity.

“This would (on the balance of probabilities) have led to a diagnosis of the problem at a time when Ms Christian’s life would have been saved.” The failure to “do that which plainly should have been done, thus leading to the failure to diagnose” was a “total and complete failure”.

Her condition deteriorated and on December 22 her partner, Mitchell Bower, tried to contact her GP, but the surgery was closed. They finally got through to a nurse at a Primecare out-of-hours call centre.

Mr Dorries said Ms Christian’s symptoms gave significant clues that she required further examination. “This consultation failed to establish or deal with that which was required. The call process was not followed.”

He said the seriousness of Ms Christian’s condition should have been flagged up. The outcome of the call should have been at least a visit by a doctor within the hour. “Her symptoms would have been plain and it is surely inevitable that she would have been admitted.” At this stage, her life would probably have been saved.

The GP was phoned again at lunchtime on December 23 and Ms Christian was admitted to hospital. Mr Dorries found that the hospital discharge on December 20 was “without appropriate inquiry or examination” and the failures of the deputising service on December 22 “amounted to a gross failure to provide basic medical attention to a person in a dependent condition whose condition was such as to show that she obviously needed it.

“There is a clear and direct causal connection with the death in that (on the balance of probabilities) Ms Christian would have survived had her condition been acted upon at either of those times.”

He recorded the medical cause of death as peritonitis with a perforated duodenal ulcer and said she died from natural causes contributed to by neglect.

Keith Bushnell, managing director of Primecare, said an investigation found the nurse “inappropriately resolved the telephone consultation with Miss Christian. The nurse is no longer working with Primecare.”

After the hearing, Ben Gent, the solicitor for Ms Christian’s family, said in a statement: “The inquest has been distressing for the whole family but they feel that it has been conducted with the level of detail and sensitivity that Alison deserved. The coroner has been critical. In this case, that criticism is deserved.”