Hospital fined after heart patient dies in scan result mix-up

Lucas Allard went to A&E late at night with chest pain radiating into his back, shoulders and abdomen

A hospital was fined £60,000 after a heart patient died following a mix-up over scan results.

Luke Allard, 28, who had a heart disorder, was sent home after a doctor at the Queen Elizabeth Hospital (QEH) in King's Lynn read an old CT scan.

The mistake was discovered two days later, but Mr Allard suffered a fatal heart attack on his return to the unit.

The hospital pleaded guilty to failing to provide safe care and treatment, exposing him to risk of avoidable harm.

It has also apologised to Mr Allard's family.

The prosecution at Chelmsford Magistrates Court was brought by the health watchdog, the Care Quality Commission (CQC).

It said the criminal offence stemmed from the trust's failure to safely manage scan reports.

District judge Timothy King found the case against the hospital was not one of systematic failure, but was instead an isolated incident.

Mr Allard suffered a fatal heart attack on his return to the King's Lynn hospital

An inquest held two years ago, which recorded a narrative conclusion, said Mr Allard, from King's Lynn, had Marfan Syndrome and was awaiting heart surgery at Papworth Hospital in Cambridge.

The genetic disorder affects connective tissue and caused the death of several members of Mr Allard's family, including his older brother in 2015.

Mr Allard had gone to the QEH in March 2019 with chest pains.

A series of tests were carried out, but a previous CT scan was assessed by the doctor looking at Mr Allard's results, which indicated he was fit for discharge, the CQC said.

The correct report showed "significant abnormality" and he was recalled to the hospital when the mistake was discovered.

Mr Allard suffered a cardiac arrest due to a ruptured aortic aneurysm soon after he arrived at the hospital.

Mr Allard, pictured with friend Bethanie Eaglen-Smith, was discharged from hospital and told to return if the pain came back

The Care Quality Commission brought the prosecution at Chelmsford Magistrates' Court

Zoe Robinson from the CQC said in a statement: "the trust's failure to ensure its staff reviewed correct scan results is unacceptable.

"If the trust had identified and addressed the weakness of its system, it could have appropriately responded to Mr Allard's condition and provided him with the urgent care he needed".

Ms Robinson said the hospital "had also failed to ensure the provider of its out-of-hours radiology service issued a verbal report when a scan identified abnormalities.

"This situation was worsened because the trust's computer system for managing scan results was outdated and incompatible with systems used by its out-of-hours radiology provider."

For the hospital, Alice Webster, QEH acting head, said: "On behalf of the trust, our thoughts and condolences remain with Lucas's family".

She said the hospital "accepts and profoundly regrets" the failings of March 2019, adding the hospital has always had a responsible attitude to safe working in all departments.

"We have learnt and taken measures to address and close the gaps this case clearly highlighted," Ms Webster said.