Death of mum after surgery in Fife hospital 'preventable' - inquiry
- Published
Linda Allan died at Victoria Hospital in Kirkcaldy
The death of a woman six days after she had knee surgery could have been prevented, a sheriff has ruled.
Linda Allan, 59, died at Victoria Hospital in Kirkcaldy, Fife, after suffering a cardiac arrest and multi-organ failure in October 2019.
A fatal accident inquiry (FAI) concluded her post-operative care "was not at the standard that would have been expected".
NHS Fife said it would "fully consider" the inquiry's recommendations.
Sheriff Susan Duff determined that Ms Allan's death might have been avoided if she had received daily reviews, including a review of her medication.
She said there were "opportunities to detect the deterioration in her condition" and take action to prevent further decline.
This included launching an "urgent medical review" when Ms Allan's pain score went from zero to 10 in just seven hours.
The mother-of-two, from Kirkcaldy, had entered the orthopaedic unit at Victoria Hospital on 15 October 2019 after injuring her right knee while stepping over a low garden wall.
X-rays revealed a complex fracture that would require surgery, but after the operation two days later her condition deteriorated.
Ms Allan's family welcomed the findings of the FAI
Ms Allan's family previously told the Daily Record Newspaper, external that she was given anti-inflammatory medication for the fracture, which reacted with a stomach ulcer.
Ms Allan became "very unwell" with stomach pain. She suffered a cardiac arrest but was resuscitated and transferred to the intensive care unit.
She had an operation which found a large perforated chronic ulcer. Surgeons then also discovered restricted blood flow to the small bowel and possibly the liver.
Doctors decided that any further attempts at intervention would likely be unsuccessful. Ms Allan died on 23 October.
The cause of death was recorded as multi-organ failure, cardiac arrest and complications of a perforated gastric ulcer.
'Drastically wrong'
In the conclusion of her 32-page determination, Sheriff Duff wrote: "The inquiry has established that the care which Ms Allan received post operatively was not at the standard that would have been expected.
"There were opportunities for her condition to be reviewed which could have altered the tragic outcome in this case."
The sheriff made eight recommendations including a daily review for every post-operative patient and an immediate referral should a patient go from a low to high pain score between observations.
In a statement welcoming the findings, Ms Allan's family said: "From the beginning we've always felt something has been drastically wrong.
"This FAI has been vital in making sure improvements can be made to the NHS so people get the care they deserve.
"It doesn't matter if it involved the NHS or someone else - no one is above the law and mistakes need to be accounted for."
NHS Fife said it wished to extend its condolences to Ms Allan's family.
A spokesperson said: "We have just received the determination from Sheriff Susan Duff and will consider fully the sheriff's findings and recommendations."