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Hospital fined after heart patient dies over a scan result mix up

A hospital was fined £60,000 after a heart patient died following a mix-up over scan results.

Luke Allard, 28, who had a heart disorder, was sent home after a doctor at the Queen Elizabeth Hospital (QEH) in King's Lynn read an old CT scan.

The mistake was discovered two days later, but Mr Allard suffered a fatal heart attack on his return to the unit. The hospital pleaded guilty to failing to provide safe care and treatment, exposing him to risk of avoidable harm.


Source: https://www.bbc.com/news/uk-england-norfolk-63904797



"Mr. Allard had gone to the QEH in March 2019 with chest pains.

A series of tests were carried out, but a previous CT scan was assessed by the doctor looking at Mr. Allard's results, which indicated he was fit for discharge, the CQC said."


"The correct report showed "significant abnormality," and he was recalled to the hospital when the mistake was discovered.


Mr. Allard suffered a cardiac arrest due to a ruptured aortic aneurysm soon after he arrived at the hospital."


"Ms. Robinson said the hospital "had also failed to ensure the provider of its out-of-hours radiology service issued a verbal report when a scan identified abnormalities.


"This situation was worsened because the trust's computer system for managing scan results was outdated and incompatible with systems used by its out-of-hours radiology provider."

 

This is tragic and preventable. The same thing happened to my Mom. As you will read in "Not in Vain, A Promise Kept," after the second round of chemotherapy, my mom was wasting and very ill. Before she got the third scheduled round of chemotherapy, we asked for her to have a cat scan to see if there was any change (progress) in her battle with ovarian cancer. We were told by the oncologist that my mom's tumor had shrunk in half. When we got the news, we were thrilled and had a little bit of hope that the treatment plan was actually working and she had a chance.


Therefore, she proceeded to get the third round of chemotherapy. The next week she had an appointment with her oncologist/gynecologist, who had very different news. She had reviewed the films with radiology, and the tumor had not shrunk; in fact, it grew.


We just made an already sick patient sicker by filling her body with poison that was not working.

To better understand the full story, it is all in the book. Every last mistake that she ultimately paid the price for.


 

As I always say, doctors are humans and make mistakes, but given the severity and length and severity of Mr. Allard's heart condition from in the link above, you would think that the radiologist would get a second head or engage another colleague to review the scan.


You will also read that the scan was done by a vendor providing "after-hour" support, and the computer notification system from the after-hour support system did not feed the results to the hospitals therefore, the doctor got a verbal "everything is good" instead of the correct results identifying multiple abnormalities and ultimately a medical emergency. The hospital paid and apologized for the malpractice that led to Mr. Allard's death.

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