A WOMAN died 48 hours after she was discharged by a junior doctor and sent home, in pain, in a taxi in the middle of the night.

The Scottish Public Services Ombudsman said she was "critical, even shocked" by the care given to the 78-year-old woman at Monklands Hospital in Airdrie, part of NHS Lanarkshire.

The pensioner was taken to A&E by ambulance at 9.58pm on May 2, complaining of severe stomach pains and vomiting.

She also suffered from multiple health problems including high blood pressure and pulmonary hypertension and had suffered three previous heart attacks and a stroke.

The woman, who has not been identified, was seen by a ‘middle grade’ emergency doctor at 12am, who suspected she might have a blockage or perforated intestine.

Further tests were carried out and she was referred to the on-call surgical team for a specialist opinion at 12.20am.

A junior doctor, described by an adviser to the ombudsman as “relatively inexperienced", reviewed her case and concluded that it was safe to discharge her home within the hour, with gastroenteritis given as the probably diagnosis.

She was not given any pain relief, despite recording three out of four on the pain scale and was put in a taxi at 2am. Her husband, who did not know she had been discharged, said he found her in her night clothes, knocking on the door and in pain.

She died two days later at home.

Rosemary Agnew, the ombusdman, said she had found "significant failings" in her care and she ordered NHS Lanarkshire to apologise to the woman's husband.

She also outlined a series of recommendations to improve care, including telling the health board that in such cases, patients should not be discharged without senior doctor oversight.

In response to the discharge of the woman, Ms Agnew said: "I am critical, even shocked, that this situation occurred at all.

"I am particularly critical that the board's own complaints investigation failed to identify any concerns about the circumstances involving an elderly and frail patient with multiple health problems being discharged home by taxi in the early hours of the morning.

"I conclude that it was unreasonable to discharge Mrs C in the early hours of the morning and not to have discussed this with Mr C in advance."

A post mortem report ruled the cause of the woman's death as ischaemic and valvular heart disease.

However an inquiry concluded that she may also have suffered acute pancreatitis, which was not identified because a “grossly abnormal” blood test result was ignored.

An adviser to the inquiry said the junior doctor was of Foundation Year Two level, a level not considered by the Royal College of Surgeons to be experienced enough to give a diagnosis in this case.

NHS Lanarkshire admitted that a full drug history had not been recorded. The first doctor had not failed to record significant parts of her medical history.

The record of examination of her respiratory system, cardiovascular system and abdomen was described as “brief and lacking in detail.”

The doctor had failed to take into account that women with heart disease are more likely to complain of abdominal pain and vomiting than men.

The inquiry concluded: “Had a more senior doctor overseen Mrs C’s care and due attention had been given to the test result, she would have been admitted to hospital which may have avoided her death.”

The inquiry found that the abnormal blood test result was also overlooked a further two times, during the health board’s investigation.

Two complaints were upheld against NHS Lanarkshire for a failure to provide reasonable care and the board has been given a deadline to implement a series of actions.

Dr Jane Burns, NHS Lanarkshire acute divisional medical director, said: “We regret any instance where we fail to provide the highest standards of care for our patients and we will contact the complainant directly to offer our sincere apologies for the failings identified in the report.

“We have fully accepted the recommendations within the Ombudsman’s report and will develop an action plan to address them. The lessons learned will be shared to help avoid similar occurrences in future.”