‘Opportunity missed’ to give ‘warm and kind’ Chichester woman better care, inquest hears

An opportunity was missed to give better care to a ‘warm and kind’ grandmother who died at St Richards Hospital in Chichester, an inquest has heard.

Friday, 29th March 2019, 9:06 am
Updated Friday, 29th March 2019, 10:15 am
Susan Carr enjoyed going on beach walks with her husband and their dogs

Susan Carr, of Wessex Avenue in East Wittering, was taken to hospital by paramedics after complaining of chest pains at just before 1am on Saturday, October 27, the inquest heard.

The 67-year-old was checked by doctors at A&E and discharged at 5.25am – however just minutes later she ‘slumped’ in her seat and was brought back to hospital, where she died.

A postmortem showed the cause of death to be a hemothorax, an aortic dissection, an aortic aneurysm and hypertension.

Her family described Susan as ‘a wonderful wife, a caring mother, a devoted grandmother and a great friend’ who was ‘loved by so many’.

She had a ‘witty sense of humour’ and enjoyed walking her dogs Marley and Jackson daily on the beach in West Wittering with her husband.

The inquest at Crawley Coroner’s Court on Tuesday heard that Susan had previously been diagnosed with rib cancer and also had a 6cm aortic aneurysm.

Penelope Schofield, West Sussex Senior Coroner, said Mrs Carr had told the ambulance service that she had an aneurysm and that they had noted it down.

However she said: “For some reason this information was not handed to the hospital when she was admitted.

“This probably was a missed opportunity for this information to go to the doctor.”

On the ward, the doctor completed a full history with Susan – however there was no mention of the aneurysm, the inquest heard.

Ms Schofield said: “We can only assume that Mrs Carr didn’t tell the doctor, or he didn’t ask the right questions.”

The doctor carried out tests and after any acute coronary issues were ruled out, Susan left the hospital.

Speaking at the inquest, Susan’s husband Michael said he was ‘extremely surprised’ she had been discharged so quickly.

Shortly afterward, she suffered a rupture of the aneurysm.

Back at the hospital she was given CPR but she was sadly pronounced dead.

The inquest heard that, had the hospital been aware of the aneurysm, Susan would have been kept on the ward and a CT scan would have been carried out.

Giving evidence, Dr Mark Witcomb, consultant in emergency medicine, said: “If the information had been gathered about the aneurysm, Mrs Carr could have been treated in hospital.

"We could have given her better care."

However, it was acknowledged that even if she had remained in hospital, no treatment would have been possible before the aneurysm ruptured.

Ms Schofield said: “She would have died in any event.

“There was a missed opportunity to make her comfortable in the hospital.

“She had the unpleasantness of having to leave hospital and found herself being brought back.”

She concluded death by natural causes.

After the inquest, Dr Tim Taylor, medical director at Western Sussex Hospitals NHS foundation Trust said: “We deeply regret the circumstances of Mrs Carr’s death and wish to take this opportunity to apologise and extend our sincere condolences to her family.

“We hope that the coroner’s investigation and conclusion that Mrs Carr’s death was due to natural causes helps at this difficult time as they grieve for their loved one.”

Susan’s family said in a statement: “Sue was loved by so many, she was a very warm and kind woman and will be sadly missed by all of her family and friends.

“She was a wonderful wife, caring mother, devoted grandmother and a great friend with a witty sense of humour to all that knew her.

“She was a animal lover and would enjoy walking daily and being part of the dog walking community on West Witterings beach with her husband Mick and dogs Marley and Jackson.”