Arthur Hall

1. 1. bowel perforation missed

   “On the 1st February 2018 the differential diagnosis of bowel perforation was abandoned without full investigation.”

2. 2. missed bowel perforation

   “The recognised first line of enquiry was an upright chest X-ray. What is known about upright chest Xray's is that they are known to miss a number of perforations. This was used to exclude the possibility of perforation when it is a known limited diagnostic tool that can miss from 20% of perforations to 50% of perforations (see literature).”

3. 3. missed bowel perforation

   “Second line of enquiry (endoscopy or CTPA) was not undertaken.”

4. 4. missed bowel perforation

   “Assumptions were made that pain was a result of surgery and therefore not considered an important indicator of a problem. The surgery is considered by practitioners to be painless, and that pain or sickness are signs of potentially serious complications.”

5. 5. inadequate discharge advice

   “Given the potential time-critical nature of [the deceased]'s possible complaint, more detailed discharge advice should have been given.”

6. 6. missed surgical opinion

   “No surgical opinion was sought when a surgical patient attended A&E with symptoms which were suspected to be related to surgery.”

No published response was found on judiciary.uk.