A MUCH-LOVED Carlisle woman died after hospital staff failed to correctly diagnose her condition, an inquest has heard.

Frances Ada Richardson, 68, died on February 13, 2021, at the Cumberland Infirmary, Carlisle.

At an inquest in Cockermouth, coroner Dr Nicholas Shaw concluded that her death was as a result of 'natural disease contributed to by neglect'.

The inquest heard that Mrs Richardson had had a lump in her stomach for four to six weeks and been vomiting. Her GP said it was a hernia and referred her to hospital for a CT scan.

Following a scan on February 8 she was discharged home and told the hernia would be repaired in the next few months.

The radiologist did not note it was incarcerated and obstructing the bowel - a condition which is treatable, the inquest heard.

Mrs Richardson continued to feel seriously unwell and returned to hospital four days later where further assessments were carried out. She died the following day.

Dr Shaw said: "It seems to me it’s very difficult to avoid the view that the wrong diagnosis was made initially and she went home. Any doctor can make an incorrect diagnosis.

"But then matters did not improve. She came back to hospital four days later. At that time I feel alarm bells should have been ringing very loud and the situation should have been reviewed.

"But instead the wrong diagnosis and wrong treatment again happened and as a result an opportunity to take action to save Frances’s life was missed."

Regarding her return to hospital when feeling so unwell, Dr Shaw said: "Surely a more thorough reassessment should have been made and a different line of action taken. We have heard how extensively it was not.

"I firmly believe that had Frances been taken to theatre after her first admission they would have found the hernia and all would have been well."

Mrs Richardson's husband, Robert, daughter, son and sister were at the inquest.

Mr Richardson had been unable to accompany his wife into hospital because of Covid. They communicated by phone.

"I phoned the hospital twice and said she was in distress and needed attention. We were pushing it the best we could but they were not taking any notice," said Mr Richardson.

A doctor phoned him the following afternoon to say she was given antibiotics.

"It did not seem very relevant," said Mr Richardson.

"I was trying to correspond with my wife and the hospital that evening but could not get an answer from anyone."

He eventually got through at about 10pm and was told that his wife had died.

He went to the hospital. "I asked the two doctors if they knew the cause of death and they said they did not," he said.

"I was upset and am still upset. In my opinion my partner of 52 years is no longer with me and it's completely unnecessary."

A post-mortem revealed the medical cause of death was bronchial pneumonia due to the aspiration of intestinal contents due to incarcerated obstructed small intestine within a paraumbilical hernia.

Dr Andrew Bow, a consultant physician at the CI specialising in renal medicine was not involved in Mrs Richardson's care but was asked to lead on Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust's significant incident investigation.

The radiology report did not note there was bowel obstruction and a surgical review did not make reference to the CT scan, he said.

On her second visit to the hospital she was reassessed for a hernia, he said. "Again they didn't see the obstruction," he said.

"Actions are being taken to improve the failures which were documented."

Solicitor Georgina Nolan, representing the family, said: "There have been a number of what the family would see as gross failings.

"The failure to recognise the bowel obstruction and act upon it. That failure started in February 8 and continued on February 12. If that had been recognised she would have been successfully treated," she said.

Ms Nolan said gross failings, according to the family, included: not properly reporting the CT scan; failing to diagnose bowel obstruction and discharging her on February 8.

On February 12 a CT scan was advised but not obtained, she said.

"It would appear she was not assessed properly, no surgical review took place until 9.30pm, shortly before she died," she said.

"This is a lady who was in a dependent situation in need of basic medical attention. That need should have been obvious to those that were treating her."

Solicitor Neil Smart, on behalf of the trust, said: "There have been failings, missed opportunities, but these do not amount to gross failings."

Dr Shaw asked Dr Bow: "Can we be assured that some learning has taken place, teams have been made aware of what has happened and what should have happened?"

Mr Smart said an action plan addresses the issues raised. Discussions have taken place and learnings would be shared with all staff, he said.

This would include learning on the duty of candour, more explicit written reports for radiology and written information being given to patients being discharged, he said.

"Radiology is very clear about what has to be done," he said.

The coroner said: "I see they have taken things on board."

To Mrs Richardson's family, he said: "It's very sad to have lost a loved one in this situation. I’m very sorry."