The family of a Perthshire man who died just hours after he was discharged from Perth Royal Infirmary have asked a sheriff to deliver damning findings against the hospital and its staff.
Ronald Gilmour died at his home in Lower Middleton, Strathtay, on April 3, 2008, after he suffered a “massive spontaneous bleed” from a burst varicose vein for the second time in a matter of hours.
Paramedics found him on the floor, next to the telephone he used to call emergency services.
The 78-year-old had been taken by ambulance to the hospital the previous evening after an ulcer “popped”, only to be released just hours later to his family’s surprise.
They pushed for a fatal accident inquiry over concerns “systematic failure” in the accident and emergency department had been responsible for the death.
That inquiry came to an end at Perth Sheriff Court on Monday, with representatives for The Crown, the Gilmour family, NHS Tayside and Dr Katherine Harper who assessed Mr Gilmour in A&E on the night before his death making final submissions to Sheriff Michael Fletcher.
Procurator fiscal Helen Nisbett told the sheriff it was her belief there were reasonable precautions that could have been taken to prevent Mr Gilmour’s death.ExplanationShe said he could have been admitted to hospital in case bleeding had recurred, while a secondary precaution could have involved a more formalised approach to discharge.
Mr Gilmour’s family could have been given a more thorough explanation of his condition, perhaps stressing the need for him not to be left alone.
Ms Nisbett said either of these precautions might have avoided the tragic circumstances that occurred.
The family’s agent Tracey Brown agreed with Ms Nisbett’s suggestions but went further, telling the inquiry that the catalogue of errors made at every level during Mr Gilmour’s treatment pointed to “systematic failings.”
During evidence, Dr Harper told the inquiry she no longer believed discharging Mr Gilmour was the correct decision. She said she “regretted every day” that certain steps had not been taken to gather more information that would have helped her better assess Mr Gilmour’s condition.
Consultant William Morrison, one of NHS Tayside’s most senior accident and emergency doctors, told the inquiry he believed the decision to discharge Mr Gilmour had been “incorrect”.HandoverHe said Mr Gilmour’s age, medical history, blood loss, medication and the nature of his complaint were “just too many considerations to make discharge a safe option.”
Dr Morrison accepted there appeared to have been a botched handover from paramedics to nursing staff, agreed the lack of observations and readings taken following Mr Gilmour’s admission was “definitely a problem” and admitted his care needs after discharge had not been made clear.
He also accepted no attempt had been made by medical staff to ascertain what Mr Gilmour’s transportation and living arrangements would be upon his release.
However, he denied there had been “systematic failures,” claiming that checks were in place which ought to have prevented the death and instead simple human error was the single greatest factor.
Counsel for NHS Tayside asked the inquiry to accept that position and described calls for a finding that there had been systematic failings as “unhelpful to all involved.”
Sheriff Fletcher told Mr Gilmour’s family that he would release his findings in writing as soon as possible.