Coroner angry over test delays

SUFFOLK'S coroner has issued a withering attack on an Ipswich surgery which failed to take a blood test for four days - a delay which could have contributed to a patient's death.

SUFFOLK'S coroner has issued a withering attack on an Ipswich surgery which failed to take a blood test for four days - a delay which could have contributed to a patient's death.

Dr Peter Dean hit out after hearing the test was delayed because of the Easter holidays - and also questioned the record-keeping at the Woodbridge Road Surgery.

Now the family of the dead woman are considering pulling out of the surgery they have been registered with for generations after a blood test fiasco which ended up with a pensioner's death.

Despite presenting symptoms including a black tongue, painful blisters and massive ulcerations, Shirley Taylor, of Cauldwell Hall Road, Ipswich had to wait 36 days until a blood test was carried out to diagnose her mysterious illness.

The 73-year-old grandmother, who died as a result of a rare condition, laid suffering in bed whilst surgery workers left a blood test, recommended by a skin specialist, on hold over their four-day Easter vacation.

When it was finally done it revealed her immune system was almost non-existent and her mysterious illness - later diagnosed by experts as Agranulocytosis - took her life in Ipswich Hospital in June last year.

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The family's concerns about a catalogue of errors at Woodbridge Road Surgery, which led to Mrs Taylor's untimely death, were upheld by a coroner yesterday at her inquest.

Mrs Taylor first went to their family's GP surgery complaining of what a doctor believed to be a routine urinary tract infection on February 20 last year.

In the 36 days leading up to her first blood test on the problem on March 26, doctors prescribed her several drugs, switching between diagnosing her with fungus and then viral related problems, before she was subsequently admitted into hospital.

The problems started three days after she was put on Trimethoprim, an antibiotic to treat a urinary infection. But the inquest ruled although the drug's listed side effects contain Mrs Taylor's illness, it could not be proved conclusively it was behind the problem.

The symptoms continued to develop after she came off the antibiotic, baffling doctors at the surgery, who called in another doctor as a “new pair of eyes” before finally sending for a dermatology expert.

Dr Stephen McCarthy, said in response to the coroner's concerns about the blood test being delayed from the Thursday afternoon before Easter weekend to the Tuesday after, “It was a situation I felt very uncomfortable about. I wondered whether to the telephone the family and explain it was not possible to do it till the Tuesday. On hindsight, it would have been better to do that.”

Greater Suffolk Coroner Dr Peter Dean said he was glad to hear a new system was in place to prevent the same mistake happening again. He ruled Mrs Taylor's death would have been inevitable, from the evidence heard, even if she had been given a blood test earlier.

He said the cause of her death could not be determined but it was due to overwhelming infection brought about by Agranulocytosis - which had severely depleted her white blood cells.

Dr Sam Gibbs, a consultant dermatologist, said the disease would typically produce three cases per million of a western population.

The Family's view:

Karen Taylor, 46, Mrs Taylor's daughter, said after the inquest: “Why did they not give mum a blood test when she first went in saying she was unwell? No-one really knew what it was (the reason behind her death) but why was the first thing not a blood test? As a doctor you would surely think 'we need to do a blood test'.”

George Taylor, 78, Shirley's husband, said: “It is going to be very difficult to get closure now.”

Linda Warrington, 50, Shirley's other daughter, said: “We are still with them (Woodbridge Road Surgery) but we are thinking of changing.”

The Coroner's view:

Greater Suffolk Coroner Dr Peter Dean criticised the communication problems which led to a note for a blood test being ignored by district nurses for four days. He also questioned inadequate records of check-ups held by the surgery, after they wrongly recorded the doctor who carried out the home blood test.

But he refused to level criticism at the lengthy diagnosis leading up to the pensioner's death, saying her condition was so rare it was almost statistically “vanishing”.

He also praised the “stoic” bravery of Mrs Taylor who fought the disease longer than medical experts would have expected her to survive.