Dad died after being mistakenly discharged from hospital with horror test result
A loving dad died at home hours after he was mistakenly released from hospital when he was at risk of a blood clot.
Benjamin Munns’ wife Sara had called 111 at 10.30am as his right calf was swollen and received a call back at 5.30pm when they were told to make their way to hospital. They arrived at the Camborne and Redruth Community Hospital at around 7pm and were seen at 9pm when Dr Ruth Faulkner carried out a D-Dimer test to look for possible blood clots, an inquest heard.
A normal person’s score is less than 230 but Mr Munns’ was 9,900 - suggesting clotting. However he was released before the result was seen and once home passed out on the floor of their family home. Paramedics were unable to save him and he was pronounced dead at the scene.
Ben's wife, Sara, told the inquest how devoted her husband had been to their children, Cornwall Live reported. She said: "He was a really good dad. We had been married for 20 years. Ben was witty and very well-read. He took great pride in his books. There were six paramedics trying their hardest to revive Ben. The care he received was phenomenal. But as he was overweight and diabetic and had DVT before, why were we discharged and not blue-lighted to Treliske when his D-Dimer results were through the roof?"
Dr Faulkner was doing only her fourth shift as an out-of-hour GP at Barncoose the night of the incident and told the inquest that she tried to help the nurse take blood from Ben as she was struggling, and suspected a possible DVT when his abnormal D-Dimer results came back, especially in view of Ben's swollen and painful leg.
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She told the inquest she did not review everything as she should have and as she was too busy and when she realised it she tried to call Ben and Sara only to find out he had already collapsed. Dr Faulkner said she was not aware that a first set of observations had been done before she saw Ben herself.
She said: "I had lots of notes on my desk and I was thinking I had seen observations and they were OK. I had observations but they were not Ben's. Sometimes I am quick, too quick to help and if I had waited I would have received the information in a timely order and established all the things I had not established at the time. This has been a big learning point for me. Not having so many notes from different patients on my desk at one time is another lesson to be learnt as that unstuck me."
Pathologist Dr Debbie Cook, who carried out the post-mortem, told the inquest she found a large coiled blood clot blocking his lung arteries, meaning a blood clot had formed into another part of his body - namely his leg. She told the inquest: “"If there is no blood going to the lungs then oxygen cannot travel to vital organs such as the brain and heart which would have led to faintness and collapse."
Recording a conclusion of natural causes, Andrew Cox, senior coroner for Cornwall and the Isles of Scilly, said Dr Faulkner should have reviewed Ben's observations before deciding on his treatment. He added: "She should have seen that his oxygen saturation appeared to have deteriorated and at the least should have asked for more observations to be done.
“The outcome of such observations would have guided her management of Ben, but it may not necessarily have led to Ben being transferred to Treliske straight away. However, if this observation had led to a worsening picture it may have been a transfer to Treliske would have been appropriate. But we can't know if the outcome would have been the same."
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