Hospital looked at two incorrect scans prior to man’s death, inquest hears
- Credit: Archant
A hospital has pledged to learn from the fatal heart attack of a man in his 20s - who died after a doctor looked at the wrong scans.
Lucas “Luke” Allard of Mill Houses, King’s Lynn, died at Queen Elizabeth Hospital (QEH) on March 14 last year, a day after being discharged.
The 28-year-old had Marfan syndrome, a genetic disorder which can cause heart issues.
An inquest into his death began last year, when Norfolk Coroner’s Court heard Mr Allard had attended A&E on March 12, complaining of severe chest pains.
He underwent a CT scan but, after the results were sent to the emergency department, Dr Masud Isham copied and pasted the wrong scan into Mr Allard’s file.
The spinal scan, of another patient, showed no abnormalities and Dr Isham sent Mr Allard home at 2.10am on March 13.
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On the morning of March 14, when another consultant was reviewing scans, the mistake became apparent and it was discovered Mr Allard had an aortic aneurysm.
He was rushed to QEH but collapsed at hospital that day.
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As the inquest continued on Monday, it was also revealed Dr Isham had referred to a second incorrect scan which belonged to Mr Allard but was from 2018 and showed no abnormalities.
Providing evidence, doctors from QEH said the hospital was putting in place measures to prevent similar errors, such as upgrading its internal computer systems.
Dr Jason Smith, a consultant radiologist at QEH, said it was “undeniable” that current systems were “not user-friendly”, while area coroner for Norfolk, Yvonne Blake, said Dr Isham had been “completely flummoxed”.
Dr Smith added that, when abnormalities are found, radiologists must now telephone the doctor who requested a CT scan - rather than asking administrative staff to do so.
A&E consultant, Dr Robert Florence, highlighted the potential effect of fatigue on Dr Isham, who finished his shift two-and-a-half hours later than scheduled.
He speculated that Dr Isham was unlikely to have taken a break, adding that he was no longer allowed to finish “beyond midnight”.
Ms Blake gave a narrative conclusion, stating: “As Lucas was being transferred from wheelchair to bed, he suffered a cardiac arrest and all attempts to resuscitate were unsuccessful.”
She said she was “satisfied” with action being taken by QEH regarding its internal system, but added: “That was not the problem here. The problem came about in reading the wrong scan and Lucas being falsely reassured”.