A woman who died in a Fife hospital following post-operative complications had been inappropriately moved to a different ward, an inquiry into her death has heard.
Linda Allan, 59, was admitted to Victoria Hospital in Kirkcaldy with a broken leg after a fall in her garden in October 2019.
She died of organ failure just days later, following a gastrointestinal bleed.
Her family has claimed her treatment was “dangerously incompetent” and the blame has been placed – at least partially – on an inappropriately-administered drug.
A fatal accident inquiry (FAI) at Dunfermline Sheriff Court heard Ms Allan was initially treated on ward 33 but was “boarded out” to ward 10.
The move was to free up space for new patients.
Move to ‘limited’ ward
Ward 10 staff nurse Susan Halfpenny felt the move was inappropriate as it treated patients whose discharge was imminent and she felt Ms Allan was in need of more comprehensive care.
She said when admitted to ward 10, Ms Allan had abdominal discomfort.
“When she came to us she was complaining of discomfort and was feeling unwell.
“She didn’t look like someone (who would be) leaving the hospital the next day.
“We are nurse-led, we don’t have doctors on our ward.
“I felt more care was needed and in my opinion she shouldn’t have been boarded out.”
She added: “When she came to us she was uncomfortable – she had stomach pain, gastric pain.
“She didn’t look well at all.
“Being nurse-led we are limited.
“We only run on two staff at night and I felt she needed more care than we could provide.”
Medical specialist evidence
Advanced nurse practitioner Sinead Webster was called in to assess Ms Allan and found her “dishevelled” and “tired”.
However she said she did not consider escalating Ms Allan’s care as a clinical assessment tool known as the Fife Early Warning Score (FEWS) determined she was low risk.
Instead she opted to provide IV fluids to counteract possible dehydration and take bloods.
She said if she had called a doctor, they would have told her to wait for the result of the test.
Clinical nurse manager Pauline Hope told the inquiry although Ms Allan reported high levels of pain, this could have been as a result of her injury rather than her stomach.
She said: “Because of the nature of Ms Allan’s injury it would have resulted in a lot of pain.
“She was admitted on the 15th an went to surgery on the 17th.
“It’s difficult to infer if the pain was because of the injury and then when you have surgery you get post-operative pain.”
However, consultant orthopaedic surgeon surgeon David Chesney told the inquiry because Ms Allan was reporting a pain score of 10 out of 10, he would have expected her to be examined by a doctor.
He also agreed reporting in medical notes where pain was located would be helpful in pain management.
The inquiry before Sheriff Susan Duff continues next week.
The background
Linda died on October 23 after a stomach ulcer burst, causing bleeding into her bowel and multiple organ failure.
One of Linda’s daughters, Shona Adams, 36, previously told The Courier: “It’s absolutely disgusting that a fit healthy woman with a broken knee died within the care of the hospital.
“We have lost everything.
“Treatment provided was dangerously incompetent really; a hazardous situation that resulted in our mum’s death which could have been avoided.”
A Significant Adverse Event Review (SAER) was carried out by NHS Fife in March 2020 and suggested the bleed may have been at least partly caused by an anti-inflammatory drug.
The family hopes the FAI will shed further light on what happened.
An FAI is only held when a death is sudden, suspicious, unexpected, accidental or unexplained or which have occurred in circumstances that may give rise to public concern.
