The death of a 59-year-old mum who died of multiple organ failure following a knee operation could have been avoided if NHS staff had paid more attention to her deteriorating condition, a sheriff has ruled.
Linda Allan, 59, died at Victoria Hospital in Kirkcaldy after suffering an adverse reaction to Naproxen, an anti-inflammatory medicine she was given following an operation on a fractured knee. Hours after the operation on October 17 2019, which she underwent after a garden wall gave way, her "pain score" shot up from zero to 10 out of 10, and she told staff she was feeling "rotten".
However, a fatal accident inquiry (FAI) into her death heard that "nothing was done to investigate" her rapid escalation in discomfort. Instead, doctors told her that her stomach pain was constipation and a reaction to the morphine she was given as a post-op painkiller.
Medics continued to give her Naproxen twice a day, despite the fact the drug was listed as a "do not take" medication on her notes. Tragically the drug reacted with a stomach ulcer, which burst, and Linda suffered a cardiac arrest four days after her operation.
Doctors carried out investigations and discovered the burst ulcer was bleeding into her bowel; they also identified signs of restricted blood flow in her small bowel and liver. Ultimately, they concluded that further surgery would be unsuccessful and Linda died at 2.15am on October 23.
Sheriff Susan Duff, presiding over the inquiry, concluded that the mum's care "was not at the standard that would have been expected". She found that NHS Fife had three crucial chances to identify the problems with Linda's aftercare that might have saved her life.
Medics, she wrote, could have reviewed her medication on October 19 and 20 as part of a daily review; they should have also escalated her for an urgent review on October 19 after her pain score shot up to the top of the scale in seven hours. Doctors also missed a second chance for an urgent review the next day which, the sheriff concluded, could have prevented her death.
In a written determination, Sheriff Duff said: "The inquiry has established that the care Ms Allan received post operatively was not at the standard that would have been expected. There were opportunities for her condition to be reviewed which could have altered the tragic outcome in this case."
She made eight recommendations for NHS Fife to adopt to prevent such an event from happening again, including daily reviews and immediate referrals to senior staff for rapid onset pain. An internal review by the health board has made similar recommendations.
Linda's family has previously told the Sunday Mail of their fury after Linda was given Naproxen despite having previously stopped using it due to side-effects. A statement issued on behalf of Linda's family has thanked the Sheriff for her "vital" determination, issued this week.
The statement read: “We really welcome the findings, opinion and recommendations of the Sheriff. We were hoping to see confirmation of reviews needed across pain management, medication and training of staff and we feel that we have that in today’s determination.
“What was additionally positive for us was to see the Sheriff noting the care our mum was not at the expected standard and that if it had been, our mum’s death could have been avoided. We hope health boards all over Scotland take on board what has been unearthed at NHS Fife to make sure everyone is safe."
The family added that they were "drained" by the FAI process, and hit out at staff who they said had "zero compassion" for what had happened to the beloved mum. They summed up: "Although we welcome the findings today, it should never have got to an FAI in the first place."
NHS Fife, meanwhile, has said it will take stock of Sheriff Duff's recommendations and has passed its condolences to Linda's family. A spokesperson told the BBC: "We have just received the determination from Sheriff Susan Duff and will consider fully the sheriff's findings and recommendations."
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