Tipton Widow Joins Irwin Mitchell In Calling For Lessons To Be Learned

A widow has called for lessons to be learned after her husband died from pneumonia 36 hours after he was sent home from A&E without anyone reviewing life-saving blood tests.

Rob Walker was referred to Sandwell District General Hospital after he visited his GP complaining of breathing difficulties and a painful cough.

A health care assistant carried out blood tests. However, a consultant discharged the 61-year-old without reviewing the results, prescribing antibiotics for a chest infection.

The father-of-one’s condition continued to deteriorate. The following evening his wife Maggie dialled 999 and he was readmitted to Sandwell Hospital where he was diagnosed with respiratory failure.

Doctors were unable to do anything and he died in the early hours of the following morning.

Following Rob’s death, Maggie of Tipton, West Midlands, instructed expert medical negligence lawyers at Irwin Mitchell to investigate his care from Sandwell and West Birmingham Hospitals NHS Trust.

It emerged that the consultant who sent Rob home had not reviewed the results of blood tests which showed he had a severe infection. Had the results been known, Rob “would have more than likely been admitted”, an internal hospital investigation found.

Medical staff had also not seen a letter from the GP referring Rob to hospital which included a working diagnosis that he potentially had pneumonia or a blood clot in the his lungs. 

A subsequent inquest ruled that Rob being sent without hospital staff checking his test results amounted to neglect.

Sandwell and West Birmingham Hospitals NHS Trust has now admitted liability acknowledging that that had Rob “received appropriate treatment, he would, on the balance of probabilities, have survived.” 

Expert Opinion

“This is a tragic case where the lack of a proper process for reviewing blood results by hospital staff has ended in devastating circumstances.

“Subsequent investigations have found that Rob was badly let down and his death could have been avoided – something that has been incredibly difficult for his family to try to come to terms with.

“While we appreciate that A&E staff face challenges and pressures it is vital that the highest standards of care are upheld at all times to protect patients.

“We now call on the Hospital Trust to ensure it learns lessons so others do not have to endure that pain that Maggie and the rest of the family have following Rob’s death.” Lindsay Tomlinson (nee Gibb) - Partner

Find out more about Irwin Mitchell's expertise in handling medical negligence cases  

Rob, a maintenance electrician, and Maggie, 60, had been together for 47 years and married for 42 years.

The couple were babysitting their grandchildren, so their daughter Sally, 41, and her husband could enjoy a night away when Rob started to complain of a cough on 24 November, 2017.

Over the coming days his symptoms worsened. Rob was unable to go to work on Monday, 27 November, and spent most of the day in bed sleeping.

On 28 November he attended an emergency GP appointment and was referred to A&E because he had low oxygen levels.

On arrival at Sandwell Hospital Rob was unable to complete full sentences. A nurse requested blood tests.

Rob, who was in a lot of discomfort and could not breathe properly, was seen by a consultant, working in A&E later that afternoon.  He made a very brief note and discharged Rob.  No chest x-ray was arranged. Maggie remembers that the consultant told Rob it was “good news” and he had not suffered a heart attack.

Maggie dialled 999 for an ambulance at around 9pm the following day. Rob was admitted to intensive care but his condition continued to deteriorate.

A specialist respiratory team was called from Leicester but Rob suffered a fatal arrest and he died at 5am on 30 November. Only then were the blood tests from the 28 November reviewed when it found they showed signs of a serious infection that required immediate treatment.

An internal hospital report investigation following Rob’s death found there was no “robust” system in place in A&E for communicating that tests had been requested or for obtaining and reviewing results in a “timely fashion”.

It added that Rob should have been admitted or recalled to hospital once his test results were known and that medical notes did not detail full discussions that took place between the patient and the consultant.

An inquest following Rob’s death found that he died as result of neglect. Mr Siddique, the Coroner for the Black Country Area, wrote to the Hospital Trust to raise his concerns and demand a review of the process for review of blood tests and ensuring referral letters are read. 

Maggie said: “The last few days of Rob’s life were terrible. He was so unlike himself. He struggled to breathe and could hardly speak. He was usually so fit and healthy.

“I was dumfounded by the decision to let Rob go home but trusted the decision of a senior doctor. However, when he continued to get worse I knew he needed help.

“I cannot fault the ambulance service or the staff who tried their best for Rob when he was readmitted to hospital. They were second to none.

“However, by this stage the damage had already been done.  I could not comprehend what was happening when he was readmitted and placed in intensive care.  To be told to say goodbye to my husband and lose him less than a minute later was a total shock – a day previously I had been told that he just had a chest infection.

“I have been left absolutely devastated by the loss of my husband, best friend and soul mate. Rob was one of life’s good guys. None of our family can believe he has gone.

“Every day is a challenge which is made worse by knowing that Rob would still be alive today if those who caring for him had just checked the blood tests. It was busy in A&E, there was people waiting in corridors.

“The consultant who discharged Rob seemed quite dismissive and I feel that he did not carry out a full investigation of Rob’s symptoms. He did not mention anything about the GP’s letter or blood tests and it was all very rushed.  He only examined Rob’s chest when I asked him to.

“All we can hope for now is that Rob’s death is not in vain. Regardless of what pressures A&E staff may be under, it is vital that they take time to fully diagnose a patient’s condition. Rob’s death is a reminder of what can happen when they fail to.”