Market Drayton father’s death could have been avoided coroner tells inquest
The death of a Shropshire father of two could have been avoided if Shropdoc doctors had accessed information about previous appointments.
Declan James Dunne, known as Decky, from Market Drayton, had an overnight stay in hospital and two Shropdoc out-of-hours appointments in three days.
But the fact he was suffering from Small Bowel Volvulus, a twisted bowel, was not picked up and he died eight days after first seeking medical help.
At the inquest into his death, which concluded in Shrewsbury yesterday, the coroner for Shropshire and Telford and Wrekin, Mr John Ellery, said his job was not to suggest liability.
He said evidence showed that Mr Dunne would probably have survived had he received the right treatment.
The 27-year-old father, of Kings Avenue, was taking to the Royal Shrewsbury Hospital on December 20 suffering from abdominal pain and vomiting. He was kept in overnight but discharged the next day with suspected food poisoning.
He went to Shropdoc on December 22 and 23 when it was thought he had gastritis.
After spending Christmas in pain he deteriorated and was admitted to hospital on December 27 but died from septic shock caused by peritonitis caused by the twisted bowel.
In giving a narrative verdict Mr Ellery said: “I do not say SBV should by have diagnosed but I do say action could have been taken that would have led to that diagnosed.
Mr Ellery said December 23 was the third occasion that Mr Dunne had sought medical attention within a short period of time. Neither doctor that saw him on that day, Dr Rebecca Chamota or her supervising GP, Dr Marwan Al-Nasiri, knew that although they could have checked, he said.
“They did not know he had been in hospital overnight, had a high white cell count or had been given IV fluid,” he said.
The coroner said the information had been available by putting Mr Dunne’s name into the system.
“I had evidence from expert, Colonel Douglas Bowley, that tests, such as an X-ray and CT scan would have identified SBV. If treatment had taken place death could have been prevented.
“It is likely Mr Dunne would have survived,” Mr Ellery said.
“He died from natural causes which could have been avoided if information about relevant previous contact, which was available, had been accessed.”
Coroner in plea over patients' records
Coroner John Ellery called for GP and hospital records to be made available to out-of-hours doctors in Shropshire.
At the end of the inquest Mr Ellery asked why Shropdoc doctors could not have access to the general, GP electronic system to help with diagnosis of patients.
He also urged that during Shropdoc appointments, doctors should have to look at the patient's previous history on the computer system, something that is currently discretionary.
"Essentially, if a patients reports with the same problem, three times in a short period of time, they should be referred to hospital for investigation," he said.
The coroner also said that patients attending A&E in Shropshire should be given a consistent message about returning if their problem did not go away or worsened.
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