Mother died after nurses missed signs she had a fatal bleed

A mother died after nurses failed to spot signs that she was suffering from a fatal bleed, an inquest heard. 

Charlotte Roscoe, 26, visited Royal Bolton Hospital in Farnworth, Greater Manchester, in January complaining of 'chest pains.' 

However in a fatal blunder, nurses failed to carry out a vital blood clot scan and instead diagnosed her with an infection and discharged her. 

The mother then died a day later at her home in Manchester from an aortic dissection - a tear in the wall of the main artery that carries blood out of the heart. 

An inquest into her death heard that one of two scans could be undertaken as per national guidance, and nurses opted for the test which does not detect cardiac anomalies. 

Coroner Michael Pemberton has warned that there was a 'missed opportunity' to save her life. 

Ms Roscoe visited Royal Bolton Hospital on January 22 this year with chest pains.

She was 'suspected' to have a viral chest infection, it was heard.

The coroner said a scan was requested to confirm if there was a pulmonary embolism, a life-threatening condition that occurs when a blood clot blocks an artery in the lung, which could take the form of two tests.

National guidance said that either a VQ or CTPA [CT Pulmonary Angiogram] could be undertaken and on this occasion, a VQ scan was done 'which confirmed that there was no Pulmonary Embolism'.

'This test would not detect any cardiac anomalies whereas types of CT scan probably would do and be likely to lead to other tests,' the coroner noted.

He said that 'no follow up' occurred on the x-ray - which showed an enlargement of Ms Roscoe's heart - and this is because a 'visual inspection of the image was considered normal'.

For this reason, the Mother was discharged from hospital at 5pm on January 23.

It was noted that the 'normal' observations seen by the clinical assessment team were last taken at just after 7am and two sets of observations should have occurred in the intervening period, but were not done.

Ms Roscoe left the hospital with a 'suspected lower respiratory tract infection', but no formal diagnosis had been made.

Upon arriving to her home in Farnworth, Ms Roscoe went to bed feeling sick - and had not arisen by the time her parents went to work the following day.

On her father's return home at approximately 3pm, she was found to be dead.

A post mortem exam found that she died of a 'dissection of the ascending aorta and ruptured root of aorta leading to haemopericardium'.

'This is a rare condition, which would have been likely to have been detected by a CTPA scan and subsequent CTAA scan that would be indicated, however this was not specifically requested,' the coroner said.

He noted the VQ test was 'reasonable' with the Royal College of Radiologists guidelines to detect whether there was a pulmonary embolism.

'Whilst there was a missed opportunity to detect the unidentified Aortic Dissection by undertaking a CT scan, it cannot be said on balance of probabilities that this would have prevented death given the catastrophic nature and low survivability rate,' he added.

In a prevention of future deaths report, Mr Pemberton raised several 'matters of concern' in relation to her death.

He said guidance from the Royal College of Radiographer states that a CTPA and VQ scan are 'equally appropriate' when considering a diagnosis of a Pulmonary Embolism.

Mr Pemberton said a more recent report by the college considered whether the VQ scans should be 'replaced' for all patients suspected of the life-threatening condition, but said it was 'unclear' whether this has been properly considered.

He also referred to evidence from a doctor, who referred Ms Roscoe for a scan.

It was heard this doctor 'thought she had requested a CTPA to be undertaken' but the form that was used to request the scan meant it would be 'vetted' and an 'appropriate mode of scan arranged following consideration by a radiologist.'.

'It was stated by the doctor that it would not be normal to speak to radiology regarding a request for a scan,' Mr Pemberton said.

'In evidence from a radiologist it was stated that a medical clinician would be expected to speak to a radiologist if there was any preference for a type of scan to be undertaken so this could be discussed.

'It appeared to me that the use of the correct form, need to be specific, provide rationale for a specific type of scan request, and liaising with radiology as appropriate was not appreciated in this case.

'As above, given that there was no radiographer involved in the After Action Report or action raised, it is unclear if this matter has been considered, or any actions taken to prevent future confusion.'

Mr Pemberton, Assistant Coroner for Greater Manchester, returned a verdict of 'Hospital Death'.

He sent the Prevention of Future Deaths report to Royal Bolton Hospital, who have 56 days to respond.