Failure by paramedics to carry out simple test led to avoidable death

Mrs Gower started feeling unwell on Christmas Day in 2017. She saw her GP on 27 December, who diagnosed gastroenteritis, but by 28 December she had been vomiting for three days and was in considerable pain. Her concerned husband called 999 and an ambulance arrived within three minutes.

Simple NEWS test not carried out

However, the attending paramedic admitted in an inquest held on 14 June 2018 that he had failed to conduct a simple, routine check that would have shown Mrs Gower needed urgent hospital treatment. Mrs Gower had a pain score of nine out of 10, but for reasons he could not explain, the paramedic failed to use the standard National Early Warning Score (NEWS), a simple tool designed to improve the detection and response to clinical deterioration in patients.

Had a NEWS assessment been carried out, it would have produced a score of seven, mandating admission to hospital. Instead, Mrs Gower was given intravenous fluids and pain relief and advised about medication for constipation and vomiting. She was told to call 999 if she deteriorated. In fact, Mrs Gower had an abnormal rotation of the stomach. Later that same day, her stomach wall perforated leading to peritonitis and she went into cardiac arrest. Mr Gower once again called the emergency services and his wife was taken to the Queen Elizabeth Hospital in Birmingham, where she died.

An unsatisfactory inquest conclusion

Despite compelling evidence and an admission of failures in their duty of care by the paramedics during the inquest, the now retired Worcestershire coroner, Mr Geraint Williams, recorded a conclusion of ‘death from natural causes’ and, summing up, said there could be no criticism of the paramedics.

Mr Gower was shocked by the coroner’s verdict when the evidence presented suggested it was likely his wife would have been rushed to hospital and survived, had that test been carried out.

Turning to Shoosmiths for help

Prior to the inquest, Mr Gower approached two law firms for help in getting to the truth, but both refused to take his case on. Mr Gower was also led to believe that the Inquest would last four days and that no one would therefore represent him. However, in fact the Inquest lasted less than a day.

Following the inquest, he approached Shoosmiths and, after listening to his story, Kashmir Uppal agreed to represent Mr Gower on a no-won-no-fee basis in a civil claim.

Kashmir said:

“I too was baffled by the coroner’s conclusion and why other law firms had turned the case down. It is clear that there were evident and admitted failings in basic care here. The NEWS assessment tool should have been used to identify that Mrs Gower was at risk and should have been urgently admitted to hospital."

Kashmir has since obtained reports from independent medical experts which confirm the opinion of surgeon Benjamin Tan, who gave evidence at the inquest, to the effect that if Mrs Gower had been treated before the bowel burst, it was more likely than not that she would have lived.

There is no possibility of re-opening the inquest, since the new senior coroner for Worcestershire, David Reid, has ruled out any reconsideration or communication, saying:

"I have no power to reopen an inquest or to reconsider the evidence heard or the conclusions reached. In those circumstances it would not be right for me or for the coroner who heard the inquest to enter into any correspondence."

Media Coverage

BBC Midlands TV video coverage

BBC Radio Hereford and Worcester

Disclaimer

This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

Who we work with