A 28-year-old woman died of pneumonia after a catalogue of errors by three GPs who failed to diagnose her condition – despite seeing her eight times in a month, an inquest heard.
Tragic Claire Marshall was sent home by one of the doctors the day before she was found dead at her home.
An inquest heard the care assistant had been seen by Dr John Frain, Dr Philip Dodgson and Dr Andrew Ratcliffe EIGHT times in the weeks before she died.
But none of them diagnosed her with pneumonia or sent her for a chest X-ray despite her family insisting her condition was getting worse.
Miss Marshall’s last appointment at Derwent Valley Medical Practice in Chaddesden, Derby, saw her sent home by Dr Frain on December 30, 2010.
But the next day she was found dead on the landing of her home in Derby.
Shockingly, Dr Frain admitted at the inquest he only wrote up his notes about the December 30 appointment AFTER hearing about her death.
Recording a narrative conclusion at Derby Coroners Court on Tuesday (12/1), the coroner ruled that neglect on the part of the three doctors contributed to her death.
Dr Robert Hunter, coroner for Derby and South Derbyshire, blasted the GPs and said there were “systematic failures” at their practice.
He said: “Claire Marshall died an unnatural death from pneumonia as a consequence of failures in her assessment and examination, and a failure to recognise that she was not responding to successive treatment regimes.
“Claire had been seen on a number of occasions over a short period of time.
“She was well known to be asthmatic and she complained of difficulty in breathing, chest tightness and a productive cough.
“She had been prescribed four course of antibiotics and three courses of steroids.
“There was a significant failure by the attendant medical practitioners in realising that, despite all this she was not improving.
“As such, her death was contributed to by neglect.
“In summary, there were a number of opportunities for Claire to be diagnosed with pneumonia.
“The evidence of Claire’s mother-in-law and father clearly demonstrate that she was progressively getting worse.
“On most, if not all, of the occasions Claire was seen by doctors, there was a failure to undertake an adequate examination.
“On considering the evidence, I would find as a fact that these failures have more than minimally contributed to her death.”
The inquest heard Mrs Marshall made repeated visits to see the three doctors in the days before her death.
She complained of a cough and urinary problems when she saw Dr Frain on November 23, 2010 and again when she saw Dr Ratcliffe three days later.
Giving evidence, Dr Ratcliffe admitted he “considered pneumonia” as a diagnosis but didn’t write it down in the records.
He added: “I accept my note-keeping was not to the required standard. In retrospect, I wish I’d written this down.”
Mrs Marshall, who was diagnosed with asthma in her teens, saw Dr Frain again on November 30, 2010 and on December 8, 2010.
She was then diagnosed with a chest infection by Dr Dodgson on December 14, 2010 and prescribed antibiotics but no follow-up appointment was made.
Giving evidence, Dr Dodgson said he had carried out a test to measure the amount of air flowing in and out of her lungs but had shredded the paper the results were on.
Mrs Marshall was seen again by Dr Frain on December 21, 2010 who told the coroner he “most likely” ordered a chest X-ray.
But the inquest heard there was no record of the X-ray being documented in the patient’s notes.
She was then seen by Dr Ratcliffe again on December 29, 2010 who didn’t record her pulse in her records and admitted he didn’t take her temperature.
The inquest heard that the day before Mrs Marshall died she was sent home by Dr Frain who examined her and said there were no breathing problems.
Giving evidence at the three-day inquest, Mrs Marshall’s mother-in-law Kathryn Marshall said: “She was very lethargic, she couldn’t really do anything.
“When I saw her, she was always lying on the settee, coughing and wheezing. We were very concerned about her.”
In a statement read out in court, her father Reginald Turner added: “By late November, she was clearly very unwell.
“She said the doctors were not doing anything to help her.”
A medical practitioner’s tribunal held in 2013 found that Dr Frain and Dr Ratcliffe “failed to adequately assess” Mrs Marshall
It also ruled that Dr Dodgson, who admitted inadequate record-keeping, “failed to arrange a chest X-ray” for her.
The inquest heard that Dr Frain is still working at the practice but Dr Ratcliffe is not and Dr Dodgson has now retired.
In a family statement released after the inquest, Mrs Marshall’s family thanked the coroner for answering “many of the questions” they had.
They added: “Claire was a precious wife, daughter, sister and auntie.
“She was a caring and kind-hearted person who always had a great sense of humour.
“We welcome the inquest into Claire’s death, which has gone a long way to providing answers to many of the questions that we have.”
Dr Ken Deacon, medical director for NHS England (North Midlands), added: “We offer our deepest sympathy to this family, who have suffered such a tragic loss.
“We acknowledge that this has been dealt with by the GMC and the primary care trust at the time, and therefore it would be inappropriate to comment further on this case.”
November 23, 2010: Mrs Marshall complained of a cough and urinary problems to Dr Frain at Derwent Valley Medical practice. Consultation lasted just four minutes.
November 26, 2010: She saw Dr Ratcliffe who made no notes on her chest complaints.
November 30, 2010: Mrs Marshall saw Dr Frain but no record of him carrying out a physical examination.
December 8, 2010: The patient saw Dr Frain again but he had no record of asking about her breathing.
December 14, 2010: Mrs Marshall was diagnosed with a chest infection by Dr Dodgson and prescribed antibiotics.
December 21, 2010: She was seen by Dr Frain but no record of X-ray being ordered.
December 29, 2010: Mrs Marshall was seen by Dr Ratcliffe who didn’t take her temperature
December 30, 2010: Dr Frain said there were no breathing problems and sent her home with a nebuliser.
December 31, 2010: Mrs Marshall was found dead on the landing of her Derby home.