THE death of a Bromyard pensioner has changed patient discharge procedures at Hereford County Hospital, an inquest heard this week.

Frederick Watson, was sent home on May 22 before scan results could confirm a blood clot on the lung - within a week he had died of a massive pulmonary embolism.

Following an investigation by hospital officials, county coroner David Halpern said there was no paper trail and something 'had gone badly wrong'.

He said the scan may not have been studied by anyone or if it was reviewed, staff were unable to trace anyone who authorised Mr Watson's discharge.

Worcester pathologist Dr Geoff Smith confirmed Mr Watson, of The Shallenge, Bromyard, died on May 28 after a massive pulmonary embolism and he had probably suffered smaller clots prior to his death.

Mr Watson saw his GP, Dr Nicholas Spicer, on May 20 with tightness in his chest and breathlessness. Concerned, Dr Spicer sent him to hospital where Mr Watson underwent tests.

Senior house officer, Dr Chan Kyaw took over Mr Watson's care but when other commitments meant he was unavailable to deal with the scan results, he passed Mr Watson's care to a colleague.

On the morning of his discharge, Dr Kyaw wrote out a prescription for medication on the basis that the scan results would reveal his patient was well enough to go home.

"I was not available to review the scan results or the patient. That is all I can say," said Dr Kyaw.

Consultant physician and rheumatologist, Dr Richard Williams was also involved in Mr Watson's care. He examined the 79-year-old the day before he went home and agreed it was likely he had a blood clot.

Medication

"In the circumstances if I had that scan available and had seen him on the morning of his discharge I would have continued with the medication and held him in hospital.

"We treat patients not results so if the scan had been negative but a patient was ill in front of me I would ask what was making the patient ill.

"We have investigated this case extensively from every angle we can. There is no evidence at all in the results that the scan was reviewed.

"We can't find anyone at the hospital who would have reviewed that scan."

The inquest heard how an internal review in the wake of Mr Watson's death has changed procedures at the hospital.

Sister in charge, Carol Harrison said in future, doctors will not write prescriptions before the patients are discharged until there is a definite diagnosis.

All the documentation has got to be completed before they even leave the ward and doctors will see the patient to say they can go home.

Mr Halpern said: "Dr Williams says that if he or any other doctor reviewed that scan probably he would have been kept in hospital.

"Dr Kyaw would have written out a prescription on the basis that this scan showed no pulmonary embolism problems. It was to be reviewed by a doctor who would make a review as to whether to sent Mr Watson home."

Recording a verdict of misadventure, Mr Halpern continued: "I am sure that the hospital and everyone are exceedingly concerned as to what went on and the systems implemented will eradicate these circumstances happening again."