In addition the 79-year-old woman, known only as Mrs X, was subjected to 'unnecessary suffering' because doctors at the Princess Margaret hospital failed to 'get to grips with her medical condition', according to a report on the case. There was also confusion among geriatricians and surgeons over who was responsible for her care.
The case has led to an urgent review of patient discharge procedures at the hospital, and Swindon Health Authority has been told to consider as a priority 'the establishment of satisfactory discharge procedures' to avoid similar mistakes. The report also recommends that the case is written up by an independent expert and 'used as a training aid for key professions and managers in the organisation - from the very top'.
The case came to light after the results of a confidential inquiry were sent out with a health authority meeting agenda by mistake.
A complaint made by the woman's daughter after her mother's death was largely upheld by an independent professional review team from Wessex Regional Health Authority. Its findings were discussed during a closed committee meeting last month.
The woman was admitted to the Princess Margaret hospital on 5 October 1990, suffering from vomiting, diarrhoea and abdominal pain. She was discharged on 16 October. She later underwent further diagnostic tests as an outpatient and bowel cancer was confirmed following an ultrasound scan on 31 October.
The report says: 'Mrs X was admitted to St Margaret's hospital (a branch of the Princess Margaret) on 5 November, and although the result of the scan was known, a locum consultant failed to spot this. Mrs X was prepared for a colopscopy, which was unnecessary under the circumstances. This procedure was postponed three times due to her deterioration.'
On 5 November, her GP told her daughter of the possible cancer but it was not until 23 November that a second locum consultant told her how serious her mother's condition was. The woman died on 8 December.
Paul Vandendale, associate general manager of the Princess Margaret hospital, said that the 'human element' had been forgotten in the discharge of Mrs X. 'We are in the throws of reviewing our discharge procedures . . . this case provides a further stimulus to do that.'