“, — (1} The abdominal x-ray report was not seen by any doctor and all subsequent…”

The coroner’s concerns

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, — (1} The abdominal x-ray report was not seen by any doctor and all subsequent diagnoses were made without knowledge of its content. (2) Although the doctor in A&E did not have had access to it at that time he stated that had he known of its content he would have referred the patient for surgical review and he would not have been discharged when he was. (3) The 2 GPs who saw the deceased on the 22° and 24% respectively stated that on the information they had Mr Hill had been discharged with a diagnosis of constipation. Had they been aware of the content of the X-ray report it would have raised the concerns which they had to the level where they would have then arranged for Mr Hill’s readmission to hospital. (4) On the 20" April there was radiological evidence of small bowel obstruction, according to the independent pathologist, most likely episodic. Over the next 4 days it became progressively worse, described by the pathologist at PM as hugely distended. The prospects of successful intervention declined over the subsequent 4/5 days. The report, when available, was not acted upon. (5) An additional concern arose separate to this. Mr Hill, when he was discharged on the 20" April, had been prescribed medication. Mr Hill should have left the hospital with that medication but none was provided to him. It is unlikely that its absence had any material effect in this case but it could in others. (6) For completeness, and it is an issue which arose in an earlier Inquest, no discharge summary was sent to the patient’s GP. This a ppears to have been an exception to normal practice and an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0362

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0