A sheriff has ruled that the death of a Kirkcaldy woman may have been prevented, had doctors treating her in hospital carried out a scan.
Following a fatal accident inquiry (FAI) at Kirkcaldy Sheriff Court, Sheriff Peter Braid has suggested that Marion Bellfield (69) might have survived if a CT scan had been taken during her treatment at Kirkcaldy’s Victoria Hospital in February 2009.
Mrs Bellfield, who lived in the town’s Chapelhill, had visited hospital on February 13 in order to undergo an upper gastrointestinal endoscopy, which aimed to investigate a narrowing of her oesophagus and to take a biopsy.
However, Mrs Bellfield collapsed and died at home two days after being discharged from hospital following the endoscopy procedure, during which time she had twice sought medical advice.
A post-mortem examination later found that a ruptured oesophagus possibly caused by the endoscopy had been one of they key factors in her death, although she was also found to have an oesophageal tumour.
While Sheriff Braid believes there were no defects in any system of working which contributed to Mrs Bellfield’s death, he ruled that the carrying out of a CT scan as the first line of investigation, especially after a doctor highlighted the possibility of an oesophageal perforation, would have been a “reasonable precaution” which might have prevented her death.
That said, the sheriff added that the tumour, which was only diagnosed in the post-mortem, “could not reasonably have been diagnosed any sooner” and had weakened the oesophagus, thus increasing the risk of perforation.
He went on to conclude that neither of the GPs who attended on Mrs Bellfield on February 13 or 15 respectively had, nor could be expected to have had, sufficient knowledge and experience of an oesophageal perforation to enable them to diagnose it.
The FAI had been told that, while normal procedure after an endoscopy is to observe a patient for two hours and then discharge them if they are well and not complaining of pain, Mrs Bellfield’s discharge was delayed after she developed a pain in her lower abdomen.
After her blood pressure dropped, consultant gastroenterologist Dr Gordon Birnie examined her and said he was not certain he could hear bowel sounds, making him suspicious of a perforation of the oesophagus in the abdominal portion.
A chest X-ray was then called for and carried out, but that showed no evidence of perforation and she was discharged.
In his findings, Sheriff Braid accepted that all of the medics who treated Mrs Bellfield had been “properly concerned” for her welfare and would not have discharged her had she been in the amount of pain described by her husband James in evidence.Preferred evidence”The element of Mr Bellfield’s evidence on which much of the evidence at the inquiry was predicated was that his wife was in agony throughout the afternoon of February 13 and still in considerable pain when she was discharged,” he said.
“None (of the doctors)… observed Mrs Bellfield to be in agony or writhing in pain, as Mr Bellfield stated, and I do prefer their evidence to his on this issue.”
Sheriff Braid also refused to accept that Dr Birnie was “uninterested” in investigating Mrs Bellfield’s complaint of pain, as Mr Bellfield tended to suggest.
As his wife had still been in discomfort Mr Bellfield called NHS 24 twice over that weekend and a GP who arrived on the Sunday, February 15, considered perforation but noted that the chest X-ray had shown no signs of it.
Later that evening, however, Mrs Bellfield collapsed in her house while attempting to go to the toilet and paramedics were unable to revive her.
Continued…
Following a review of her death NHS Fife now routinely carries out a CT scan as the first line of investigation, although prior to that the practice to investigate suspected perforation within Fife was to proceed by chest X-ray.
After hearing the evidence, Sheriff Braid added that the CT scan course of action would have “significantly increased” Mrs Bellfield’s chances.
“If a perforation had been diagnosed, or strongly suspected, there was again general agreement that the appropriate treatment in the first instance would have been to admit Mrs Bellfield to hospital, prescribe ‘nil by mouth’ and administer antibiotics pending a further examination by CT scan or contrast swallow,” he said.
“It is not possible to state that the death would not have occurred had that course been followed but on any view of the evidence it might have been prevented.”
However, he added that he had been satisfied that what Dr Birnie did following his instruction of the chest X-ray was reasonable and there was nothing else which he ought to have done thereafter.
“Moreover, in instructing a chest X-ray in the first place as the first line of investigation he was not only acting in accordance with established practice at the Victoria Hospital at that time but the practice itself was a reasonable one,” he concluded.