Queen Elizabeth Hospital announce changes after mistake led to death of King's Lynn man
Lynn's Queen Elizabeth Hospital has made changes as a result of an error which led to the death of a 28-year-old patient last year, an inquest has heard.
Lucas Allard, who lived at Mill Houses in Lynn, died on March 15 2019 with a ruptured aortic aneurysm as a result of Marfan syndrome.
The technological support worker for Currys was admitted to hospital on March 12 with chest pain which had spread to his back and shoulders.
After receiving morphine he was discharged after a doctor had mistakenly looked at the wrong CT scan for another patient.
Today's inquest heard the wrong scan was copied and pasted into the computer system by Dr Masud Isham which falsely showed no abnormalities for Mr Allard.
Another consultant reviewed the scans of A&E patients after Mr Allard had returned home, and realised a mistake had been made.
Mr Allard was subsequently called back to hospital on the morning of March 14 and suffered a heart attack as he was being transferred from his wheelchair to bed.
The inquest heard he could not be resuscitated and he was due to have a surgical operation at Royal Papworth Hospital, a specialist lung and heart hospital.
Mr Allard had a history of Marfan syndrome in his family which resulted in his mother's passing in 2013 as well as his older brother in 2015. He had the same surgery his brother was due to have at Papworth.
As a result of the mistake at Lynn's hospital, consultant radiologist Dr Jason Smith told the inquest the hospital is in the process of purchasing a new computer system which will reduce some of the manual steps and be more user-friendly.
Dr Smith added that the error could have been avoided if the radiologist working at the time had spoken directly to a secretary and if Dr Isham had looked at the date of the report.
The inquest heard the hospital will ensure any abnormal radiology results will be reported immediately, and that contributing factors such as an overcrowded emergency department, staff multi-tasking and fatigue had an influence on the error.
In response, area coroner Yvonne Blake said: "The A&E is always crowded and busy, and doctors and nurses are always tired, that is the nature of the beast. What I was concerned about in hearing the evidence is that Dr Isham did not seem to be able to explain what had gone wrong in what seems to be a basic concept.
"If you are getting a CT scan on your computer it would be nice for you to have the right report and date. It's not rocket science is it?"
The inquest heard the computer system used by Dr Isham requires several programmes to be running at once and can be slow to use. Dr Isham had also been asked to work beyond his finishing time of 1am due to the demands on staff at the time. He did not finish until 3.30am.
As a result, the hospital has reduced the pressure on staff working overnight and Dr Isham took part in a meeting in which the computer system was discussed. The meeting heard Dr Isham was a senior doctor who had plenty of experience with the system.
Dr Govindan Raghuraman, deputy medical director at the hospital, said multiple software continues to be used in many parts of the country and the QEH has now changed to Windows 10 to improve the speed at the Gayton Road site.
He added: "In terms of the staff, especially temporary staff, there is formal induction training with the guidelines and IT systems so they are familiarised with in-house training.
"We tend to appoint people in temporary positions for longer periods of time to have that support and induction to understand what is necessary to undertake that job."
Dr Raghuraman told the inquest there are special precautions to ensure doctors are not overworked.
A statement from Mr Allard's South Wootton surgery said he had been "feeling low for quite some time" in December 2018 and was worried about having the same surgery his brother had received.
It added that Mr Allard had no thoughts of suicide and had been granted time off work as he agreed to take part in counselling sessions.
The coroner said the question of whether Mr Allard would have survived the operation at Royal Papworth is speculation.
Giving a narrative conclusion, Mrs Blake said: "It [the error] was not revealed until March 14, a scan was sent to Papworth and Lucas was eventually reached and asked to return to A&E as soon as possible. He had a cardiac arrest when being transferred from his wheelchair to bed and there were unsuccessful attempts to resuscitate him."
She added: "I am satisfied the hospital has put in place such measures which would have improved the things that happened in Lucas' case. This includes a direct call to the radiographer telling them if there is a problem and no delays in the information being recovered.
"There are new computer systems they say and I have no reason to dispute that. There is no one system which fits all. I know the Norfolk and Norwich has two and we heard about training.
"The problem was that it was recognised the error came in reading the wrong scan and falsely believing Lucas was okay to be discharged."
An inquest into the death was adjourned in November 2019 as the coroner requested more evidence to be collated on the hospital's computer systems.
Following the inquest this week, Dr Govindan Raghuraman, deputy medical director at the Queen Elizabeth Hospital said: “On behalf of the Trust, I extend my condolences to Mr Allard’s family and friends.
“We have learnt from this case and made a number of improvements since Mr Allard’s death to prevent a recurrence, including simplifying our administration processes.”
A memorial fundraiser has been set up online for Mr Allard with more than £3,200 currently being raised after an initial target of £3,000.
Organised by Bethanie Eaglen and six others, the page reads: "What has happened is beyond comprehension and we are all still in shock. Lucas was the gentlest, most loving and giving person you could ever wish to meet. He was the man everyone gravitated towards if you needed help or a cuddle.
"He especially loved to laugh, if he wasn’t the one telling the bad jokes, he always appreciated being told them, his laugh was so infectious. He would be the one who went to the shop and came back with flowers just because he thought they were nice and someone may like them.
"Lucas was just a bundle of pure positive, happy energy, even when he was annoyed it was never for more than a few minutes. We were all blessed to have him in our lives and to have the memories that we had with him.
"For such a gentle person, life really did deal him some horrible cards. Unfortunately, Lucas was suffering from the illness, Marfan syndrome, which sadly also took the lives of some of his loved ones, including his mother and brother only a few years apart from each other, he adored them and was always talking about them."
Visit https://uk.gofundme.com/f/memorial-fundraiser-for-lucas-allard to see the GoFundMe page set up in Mr Allard's name.
