'Neglectful' NHS told dying woman to take laxatives

A 36-year-old mother of four died in agony as a result of "gross" errors by NHS staff made on two separate occasions, an inquest found.

Alison Christian's death from a perforated duodenal ulcer two days before Christmas 2005 came after what the coroner described as a "gross failure to provide basic medical attention".

In the days before she died, she made two visits to the Northern General Hospital in Sheffield and called a GP out-of-hours service. But staff failed to recognise the seriousness of her condition until she was "beyond help". One nurse advised her to take laxatives.

Christopher Dorries, coroner for South-West Yorkshire, criticised the hospital and the GP deputising service Primecare, which he said were guilty of neglect.

"On the balance of probabilities, Ms Christian would have survived had her condition been acted upon at either of those times," he said.

Mrs Christian collapsed on 19 December as a result of peritonitis (inflammation of the lining of the abdominal cavity) triggered by the perforated ulcer, which caused her to cry out in pain.

Her partner of 20 years, Mitch Bower, returned from work to their home in Sheffield to find her lying on the upstairs landing. He dialled 999 and took her to the Northern General Hospital, where she was told she had a chest infection, a diagnosis the coroner said was "entirely reasonable".

But the nextday, when she returned to the accident and emergency department with a racing pulse, shallow and rapid breathing and severe back pain, staff failed to act on the warning signs. Her abdomen was not examined. Had it been, it would almost certainly have shown signs of tenderness or rigidity, and her blood pressure was not taken, the coroner said.

The failure to conduct these basic tests, which led staff to miss the correct diagnosis, was a "total and complete failure", he said.

Two days later, her condition had deteriorated and she called the local GP out-of-hours service complaining that she had been vomiting a "black tar-like substance" and that she had severe pain, dehydration and constipation. The nurse who took the call said her case was not serious enough to call out the emergency doctor, and advised her to take laxatives for the constipation.

The coroner said the nurse had "totally failed" to deal with the case. "Had Ms Christian been seen by a doctor at this stage ... it is surely inevitable that she would have been admitted," he said. Even at this stage it was likely her life would have been saved, he added.

A GP called out the following day arranged for Ms Christian's immediate admission to hospital, but she died shortly afterwards.

Outside the court yesterday, Mr Bower issued a statement through his solicitor describing the family's distress but praising the inquest for its "detail and sensitivity". "The coroner has been critical. In this case, that criticism is deserved," the statement said.

The hospital and Primecare apologised for their role in the tragedy.

Notorious misdiagnoses

Mathilda Cooper

The 19-year-old died from malaria soon after returning from Uganda to her home in South Wales. Her GP and NHS Direct both misdiagnosed her fever as flu. The coroner said at an inquest in January that her death could have been prevented.

Penny Campbell

The 41-year-old from Islington, north London, died of complications following a minor surgical procedure in March 2005 despite speaking to eight doctors from the north London out-of-hours GP service, Camidoc, in 2005. The coroner said their misdiagnoses had contributed to her death.

Roger Lewis

Diagnosed with throat cancer two years after visiting his GP with a sore throat. The GP in Stourport on Severn, Worcester, prescribed antibiotics but missed the lump in his neck. He was suspended for a year by the General Medical Council in 2005.

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