NHS boss: Patient who later died should not have been sent home

A PATIENT who died within hours of being sent home from hospital after he was treated for a burst varicose vein should never have been discharged by doctors, a fatal accident inquiry heard yesterday.

NHS Tayside, the health board that failed Ronald Gilmour, 78, sent an apology to his relatives in the wake of his death.

Professor Stewart Forsyth, medical director of NHS Tayside, had frankly admitted that Mr Gilmour should never have been sent home and that he had not been treated properly.

He said Perth Royal Infirmary had been responsible for failing Mr Gilmour and had fallen below an acceptable standard of care in treating the pensioner.

A fatal accident inquiry at Perth Sheriff Court heard members of Mr Gilmour's family accuse the hospital of neglecting Mr Gilmour in a bid to meet patient target times.

His daughter, Wendy Norrie, 53, said the family had pushed for an inquiry into her father's death over concerns that the hospital suffered from systemic failures.

She said she was concerned the problems would continue to lie dormant at Perth Royal Infirmary until another family was left to suffer in the same way.

Mrs Norrie accused the hospital of discharging Mr Gilmour - who had suffered huge blood loss - without taking proper recordings of his status, in order to meet a four-hour target time.

"It seemed to be a target in dad's care," she said. "He was discharged just before the four-hour time target was reached. As a family, from the beginning we were concerned there had been systemic failure."

Mr Gilmour fell ill at his Perthshire home on 2 April, 2008, when his varicose vein "popped" and started bleeding profusely, and he was taken by ambulance to Perth Royal Infirmary.

He was seen by staff but no-one removed his bloodstained trousers, which were causing him discomfort, and his blood pressure and other readings were not regularly taken.

The inquiry was told that no-one asked about the extent of his blood loss at home, despite family members repeatedly mentioning his use of the blood-thinning drug warfarin.

He was sent home later the same evening, even though medical staff had made no checks on his home care arrangements.

Mr Gilmour called an ambulance again a few hours later, but medics struggled to get into his home and he had died by the time they reached him.

Family members made a formal complaint about the standard of care he had received and Prof Forsyth, who has since retired, apologised in a letter after an internal investigation.

The inquiry was told he wrote: "It is clear the care he received was below the standard expected. I wish to sincerely apologise on behalf of NHS Tayside.

"We accept the absence of appropriate and regular recordings of vital signs. Staff underestimated the seriousness of his condition. The decision to discharge him was incorrect."The A&E department was very busy on the night he attended. All staff have been made aware of the issues and were all devastated by what happened."

However, he denied the hospital had suffered from systemic failings and rejected the suggestion that Mr Gilmour had been sent home to meet a target time.

The inquiry, before Sheriff Michael Fletcher, continues.