King's Lynn heart patient died after CT scan mix-up
A man with a heart disorder and chest pain died two days after a doctor viewed the wrong scan and sent him home, an inquest heard.
Lucas Allard, 28, went to A&E at Queen Elizabeth Hospital in King's Lynn, Norfolk, where tests were carried out. An inquest in Norwich heard he was discharged when a previous CT image was looked at by mistake. He was recalled to the hospital, after the correct scan was seen, but died soon after he arrived. He suffered a cardiac arrest due to a ruptured aortic aneurysm. Area coroner Yvonne Blake, who recorded a narrative conclusion, said Mr Allard had Marfan syndrome and had been awaiting heart surgery at Papworth Hospital in Cambridge. The genetic disorder affects connective tissue and had caused the death of several members of Mr Allard's family, including his older brother in 2015. 'Flummoxed' doctor Late at night on 12 March 2019, the technological support worker from King's Lynn went to A&E with chest pain, which he said was radiating into his back, shoulders and abdomen. A&E doctor Masud Isham ran a series of tests but called up the incorrect CT scan, from the previous November, when assessing the results. It showed nothing critically wrong, while the correct CT scan showed abnormalities in the aorta. Recalling evidence from an earlier hearing, Mrs Blake said the "flummoxed" Dr Isham was "not quite sure" how he made the mistake. "There seemed to be a lot of confusion over the IT system in place at the hospital at the time," said Mrs Blake. 'Pain was subsiding' She added: "I asked him why he discharged a 28-year-old man with crushing chest pain; he knew he had Marfan syndrome, and was awaiting an operation. "He said the ECG was normal, there was nothing abnormal about his blood, and he had said the chest pain was subsiding. "He said had he seen the [CT] report, he wouldn't have sent him home." Mr Allard was discharged at about 02:00 GMT and advised to return should the pain come back. He was recalled when the correct scan was seen by a consultant reviewing referrals from overnight. 'Tired brain' A&E consultant Robert Florance said he tried to replicate what Dr Isham may have done while trying to find a CT scan on the IT system. "When we click on something and nothing happens, we tend to click on it again, then something opens up behind and I think that's when the other report appeared," he said. "If you have been told there is something there, your brain - a tired brain - sees something that may not have occurred." Mrs Blake was told that since Mr Allard's death, a referring doctor will receive a phone call from radiology to discuss any abnormal scan, instead of an "admin" call to say a report was available. "If radiology had phoned [Dr Isham] themselves, the situation could never have occurred - they could have told him what the abnormality was," said consultant radiologist Dr David Smith. Mrs Blake said she was satisfied that various computer systems, which she described as "unwieldy", were due to be replaced by the hospital in May 2021.