Trust Admits GP Failings After Staffordshire Man Is Sent Home To Die On Christmas Day

Illness Misdiagnosed As Muscle Strain


The family of a Staffordshire man, who died from blood poisoning on Christmas Day 2007, after a doctor wrongly diagnosed a life threatening illness as a groin strain, have welcomed a local Trust’s admission that a second opinion would almost certainly have saved his life.

Father of one, Malcolm Drake, (23) from Blurton in Stoke on Trent developed an abscess, following a perforation in his bowel, as a result of undiagnosed Crohn’s Disease.
However, just three days before his death, a locum GP working out of hours, on his first day at the A&E Department of North Staffs University Hospital, misdiagnosed Malcolm’s condition as a simple muscle strain and told him to go home – despite being in so much pain that he was unable to walk.
Following Mr Drake’s death a Serious Untoward Incident Investigation was carried out by University Hospital of North Staffs NHS Trust to review the issues of GPs working in its A&E departments. Now Stoke on Trent Primary Care Trust has admitted that the locum GP they employed, who examined Mr Drake, should have sought an immediate second opinion from a senior hospital doctor.  They have further admitted that had such an opinion been sought Malcolm would have been admitted to the hospital and urgent curative surgery could have taken place.
Lindsay Gibb, a medical negligence expert with Irwin Mitchell Solicitors, represents the family. She commented: “I very much welcome the PCT’s admission of responsibility and its intention to write to Malcolm’s fiancée, Sophie Lindop and his family to offer a formal apology.
“Sadly, this will not turn back the clock and the family hope that important lessons have been learned as a result of Malcolm’s death.

“On 22nd December 2007, Malcolm had been rushed to hospital by emergency ambulance. On that day Dr Aw, a locum employed by the PCT, was working in the A&E department whilst facilities for an on-site minor injuries unit were established.  The system in place at the time meant that it was very much ‘pot luck’ whether Malcolm was seen by a member of A&E staff or by a locum GP, employed on an agency basis by the local PCT.

Unfortunately, somebody decided that Malcolm had a ‘minor injury’ and so could be seen by the locum GP rather than the hospital staff, despite his poor physical condition and the fact he had already attended the same A&E department nine days earlier with the same symptoms.

“One of the findings of the Hospital Trust’s own investigation revealed that, had Malcolm been seen by any other doctor working in A&E that day, he would probably have been referred for senior review, particularly as we understand that there is a protocol that anyone who attends A&E with the same symptoms within a short period of time ought to be reviewed by a senior member of the department.  It is not clear whether the GP in question was even aware of this protocol or had received any relevant training as to department protocols and practices. 

“We very much hope that arrangements for GPs working in A&E departments have been thoroughly reviewed and steps taken to ensure that if they are allowed to continue to work alongside hospital clinicians, they are properly supervised, trained and managed to avoid such tragic consequences occurring again.”

An inquest held in April 2010, which recorded a narrative verdict, heard that Mr Drake, who worked in traffic management for distribution company, Blue Arrow, first became unwell in early November 2007. He began suffering from diarrhoea and sickness together with severe stomach pains. Initially he was told it was a simple stomach bug but, in the following weeks, the symptoms became worse. He lost his appetite, developed unbearable pain in his abdomen and a swelling in his leg.  He struggled to walk and was bent double in pain.

He was seen by his own GP, A&E clinicians and an out of hours locum GP on a total five occasions over a period of six weeks but each time was told he was suffering from a groin strain or muscular disorder.  When he returned to Stoke based University Hospital just three days before his death he was seen by a locum GP who had been allowed to work in A&E whilst the out of hours GP clinic premises, where he should have been based, were finalised. It was his first day working at the hospital. 

Mr Drake’s fiancée, Sophie Lindop, commented: “I am relieved that the PCT has admitted mistakes were made but it doesn’t take away the anger I feel that Malcolm should still be alive today. Our little boy, Zak is now 3 years old. Sadly he will never remember his Daddy and has been robbed of all the time they should have had together.

“At times it’s been incredibly hard to cope but I’ve had to carry on for the sake of our son. Malcolm was a devoted father and as Zak grows up I will make sure he knows what a wonderful man he was.”

Recalling events on 22nd December that led to Malcolm’s death Sophie recalls: “Malcolm was in a terrible state. I had never seen him like this before and he was shouting out in pain. He had collapsed whilst at home alone and had to shuffle across the floor to call an ambulance. On the way to A&E he had to have gas and air as he was in so much pain. I couldn’t believe it when he was seen by an out of hours locum GP who repeated that it was probably just muscle strain and told Malcolm to get dressed and go home.

“I had to get him a wheelchair to leave the hospital as he was too ill to even walk.  I somehow managed to get him back home and struggled to get him out of the car. Once in the house he collapsed in the lounge.”

By Christmas Eve, Malcolm was unable to move from the sofa and was being constantly sick. A further phone call was made to the couple’s GP surgery but a doctor did not visit Malcolm at home.

On Christmas Day, at Malcolm’s insistence, Sophie took their 5 month old baby son, Zak, to her mother’s for Christmas Dinner. “I really didn’t want to go, but Malcolm really wanted Zak to spend time with his grandparents. The whole time I was there I felt uneasy and I rang Malcolm repeatedly to make sure he was ok. When I phoned at 1.45pm I got no answer and I just knew something was wrong.”

Sophie returned home, accompanied by her father, to find Malcolm unresponsive. “I walked into the house and the Christmas tree lights and TV were still on.  I found Malcolm on the sofa and I knew instantly that he was dead.  I called 999 but my Dad had to take over as I was unable to speak.” 
Sophie’s father desperately attempted to resuscitate Malcolm but when paramedics arrived they confirmed that he was dead.

A post mortem confirmed that Malcolm had died as a result of sepsis (blood poisoning) brought about by a peri-ileal abscess (bowel abscess) which had developed as a result of undiagnosed Crohn’s Disease.

If you or a loved one have received negligent medical care from your GP you could be entitled to claim compensation. Visit our GP Negligence Claims page or our Misdiagnosis Claims page for more information.