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Foreign Locum’s ECG Error Contributed To Woman’s Death

Family Welcome Lessons Learnt After Inquest


The family of a woman who died after a foreign locum doctor failed to spot that she was having a heart attack are asking for lessons learnt from their devastating case to be shared throughout the NHS to prevent future, needless tragedies.

Irene Mitchell, 59, was rushed to Doncaster Royal Infirmary on 17th of December 2009 with severe chest pains when Dr Ali Mehri failed to read the results of an ECG correctly and sent her home without treatment.

As her condition deteriorated the mum of two returned to the hospital again for help, on the 20th December 2009, she was not transferred to the Coronary Care Unit for surgery at Northern General until two days later. Tragically, she died on Christmas day before the surgery could be performed.

Yesterday (Tuesday 19 July) the family attended Doncaster Coroners Court where they heard Coroner Nicola Mundy record a narrative verdict. She also said that failure to act upon the ECG and administer urgent treatment had contributed towards Irene’s death.

Following the inquest, the family said that although nothing will ever bring her back they were relieved to have some answers so they could begin to try and move on with their lives as best they can.

The family’s lawyer, medical law and patients’ rights expert Beth Reay from law firm Irwin Mitchell’s Sheffield office, said that following the tragic chain of events which led to Irene’s death the Doncaster and Bassetlaw Hospitals NHS Foundation Trust had recognised failures involved in Irene’s case and apologised to the family.

She said: “The failure to read the results of Irene’s ECG test  in this case led to a lengthy delay in diagnosis and by the time her cardiac problems were eventually recognised the opportunity to give her drug treatment, which may have saved her life, had been missed.

“An investigation carried out by the Trust, which is responsible for Doncaster Royal Infirmary, identified that there were failures during Irene’s admission which has been devastating for her family.

She continues: “Although we welcome the changes the Trust has made at Doncaster Royal Infirmary since Irene’s death, and the apology made to the family, the Mitchells want assurances that lessons learnt will be shared throughout the NHS to prevent any other family from suffering.”

The Coroner also heard yesterday that Dr Ali Mehri who discharged Irene on 17th December after failing to act on her ECG:
- had received no induction or training when he arrived at the Trust, having previously worked in Qatar
- had been recruited via an agency just  three weeks before Irene’s death occurred

The Coroner also heard that:
- existing staff had raised questions about his clinical methods and the standard and speed of his work
- the Clinical Lead of the department had planned for him to be ‘closely monitored’
- despite concerns, he was  one of the most senior Doctors in the A&E department on 17 December 2009, one of the busiest times of the year over the Christmas period

Irene’s husband Melvin Mitchell, and his children Sadie and Glenn, have been devastated by Irene’s death.   Commenting on his family’s tragic loss, Melvin said: As a family we’ve been devastated to learn of the catalogue of errors that occurred during Irene’s treatment at Doncaster Royal Infirmary. She did not receive the care she needed because of avoidable errors which led to her being discharged home instead of being admitted. We kept telling hospital staff that she was seriously ill but were repeatedly reassured.

“We hope that lessons learnt will be shared nationally to prevent any other families having to endure the distressed we’re suffering.” 

Beth continues: “Patient safety must be a priority for all hospital staff, whether they are employed on a temporary basis or not. We have repeatedly called for improvements in safety standards and hope that as a result of the trusts investigation into Irene’s death that future tragedies can be avoided.”