Locum consultant had no 'convincing explanation' for not seeing patient who died after being sent away from hospital
PUBLISHED: 16:24 11 June 2019 | UPDATED: 16:24 11 June 2019
A coroner has written to Norfolk's busiest hospital following an inquest into the death of a man from High Kelling.
Brian Havard, 52, died on January 9, 2018, after he had been rushed to the Norfolk and Norwich University Hospital (NNUH) the night before with chest pain and vomiting.
The report, which was issued by Area Coroner for Norfolk Yvonne Blake, said Mr Havard waited in the back of the ambulance for several hours and was finally admitted at 6am and seen by a doctor an hour later.
But after he was discharged with a diagnosis of musculoskeletal pain, he collapsed in the car. An ambulance was called, but he died on the way back to hospital.
At an inquest into his death in March Ms Blake gave the medical cause of death as an acute aortic dissection and said she had concerns about his care.
Now her report, which was sent NNUH chief executive Mark Davies, gave details on what needed to change to prevent future deaths.
MORE: 'I want to know what happened to Brian' - Widow's bid to shed light on death of man who was discharged from hospital just hours earlier
The report said: "The doctor had not read the ambulance electronic records and was not aware of a system in place to obtain these notes."
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The notes said how Mr Havard had haematemesis (vomiting blood) and had been given two doses of morphine.
After the doctor examined Mr Havard he sought guidance from a locum consultant, who also did not ask to see any notes.
Ms Blake said: "He did not give any convincing explanation for not seeing this patient [...] he did not give a convincing explanation for not reviewing the patient."
Ms Blake also said there did not seem to be a system in place for junior doctors who have approached a senior doctor to have their case reviewed.
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And she added: "Record keeping generally appeared to be poor and this doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these note or read."
The NNUH has 56 days to respond to Ms Blake with details of action taken.
Following the inquest Professor Erika Denton, NNUH medical director, said: "A full and thorough review of the care [Mr Havard] received at NNUH took place and Mr Havard's family have been fully informed throughout this process and the lessons that have been learnt following his death.
MORE: Coroner calls for improvement in handling of medical notes
"An action plan has been put in place to ensure that we learn from what happened - this includes further training for emergency department staff and we have developed and expanded our Rapid Assessment and Treatment areas for patients arriving at ED by emergency ambulance.
"Formal teaching sessions about aortic dissection have taken place in ED and we are grateful to Mrs Havard who recently attended the department to talk with staff."