Six doctors missed chances to save 20-year-old’s life, inquest told

SIX separate doctors and other medical staff failed to diagnose a deadly blood clot in an otherwise fit and healthy 20-year-old, an inquest heard.

Despite Charlie Lowden being brought in by an ambulance on November 27, 2009, suffering from severe back pain and breathlessness, as well as vomiting blood, his case was overlooked.

He was taken straight to the resuscitation room at Ashington’s Wansbeck General Hospital, but was discharged by a junior doctor the next day following a diagnosis of a viral infection and after the possibility of an abscess had been ruled out.

Accompanying Charlie in the ambulance was his mum Lynn who had brought a letter from the family’s doctor saying he suspected a pulmonary embolism or blockage of the main artery of the lung, but it was ignored by hospital staff.

According to a diagnostic system devised by the British Thoracic Society, Charlie, of Rosalind Avenue, Bedlington, was not considered to be at risk of a pulmonary embolism because he did not tick enough boxes.

Ten days later, after suffering a massive clot in his right lung, the scaffolder was dead.

He was found collapsed in the bath on December 9 by his girlfriend Emma, but it is not known how long he had been without a pulse. He was pronounced dead in hospital after resuscitation attempts were abandoned.

Two separate post-mortems concluded that Charlie’s medical cause of death was a pulmonary embolism caused by a deep vein thrombosis which had travelled to his lung from his left leg.

A two-day inquest, held at Wansbeck Business Park in Ashington, heard that warning bells should have been ringing because Charlie had recently had routine day surgery to repair a hernia, and immobility, especially after abdominal surgery, is considered a risk factor.

An x-ray also showed shadowing on his lung.

He also scored four on a medical warning scale used by the trust, just one point below someone requiring intensive care, at the time of his discharge.

Dr Colin Doig, a consultant cardiologist at North Tyneside General Hospital, carried out an emergency care assessment as a result of Charlie’s death, and he said discharge documentation would now be modified to include those scores.

The Lowden family’s barrister, Robert Sowerby, asked him: “If that had been in place in this case, then Mr Lowden wouldn’t have been discharged?” “That’s correct,” Dr Doig replied.

Charlie’s death had been so sudden and unexpected it initially prompted an investigation by the police.

Lynn said Charlie had started retching on the way home from hospital and had been sick the moment they got back.

She told the inquest: “I said ‘why don’t we just go back?’ and he said ‘for God’s sake, mother, don’t be so obsessive. They’ve told you there is nothing wrong with us’.”

Cardiologist Dr Craig Runnett, the consultant in charge of Charlie’s care, said: “It seemed to point more to an infective cause than a pulmonary embolism.

But he added: “We couldn’t 100 per cent rule out that this was a pulmonary embolism.”

North Northumberland coroner Tony Brown recorded a narrative verdict outlining the circumstances leading up to Charlie’s death.

He said he intended to write to the foundation trust and the British Thoracic Society to ensure lessons are learned from the tragedy.

Mr Brown called Charlie’s death “a very sad case” and paid tribute to his family, whom he said had “behaved with complete dignity and composure in what must have been a harrowing experience”.

Jim Mackey, chief executive of the trust, said: “We are deeply saddened by the death of Mr Lowden and have expressed our sympathy to his family.

“Mr Lowden died of a rare complication of surgery which we have fully investigated.

“The report of this investigation, which we shared with Mr Lowden’s family, highlighted areas of care where we felt we could improve, and we have implemented new systems as a result of this.

“For example, we have introduced a section on the admissions form which asks all patients specific questions about risk factors for blood clots and pulmonary embolism.”