A tragic incident unfolded as a woman passed away following a prolonged wait for prescribed medication, ultimately leading to her demise, as determined by a coroner’s investigation.
Theresa Lydon tragically lost her life during a medical procedure at South Tyneside District General Hospital in South Shields on September 18, 2022, due to a sequence of deficiencies in her treatment for ulcerative colitis. Reports from the inquest revealed that Mrs. Lydon was diagnosed with the bowel condition in May 2021 and was prescribed the drug balsalazide. However, the medication was not dispensed until June the subsequent year, causing a significant delay in her treatment.
Furthermore, Mrs. Lydon was deprived of assistance from specialized inflammatory bowel disease nurses after a referral to the community service stalled. In the period leading up to her passing, she was repeatedly hospitalized between July and September 2022. Initially, the ulcerative colitis and an infection were identified in July, and appropriate treatment was administered.
Despite being discharged upon showing improvement, the severe ulcerative colitis persisted, indicating the likelihood of requiring further medical intervention. Subsequent readmissions to the hospital in August 2022 failed to recognize the severity of her condition until her final admission.
The coroner’s investigation highlighted a critical lapse in not conducting blood tests during one of her hospital stays between August 8 and August 15. This failure impeded the medical team’s ability to assess the extent of her illness accurately, potentially affecting the course of treatment and her survival.
As her health deteriorated, alternative treatments proved ineffective, leading to the consideration of surgery as the last resort. Tragically, Mrs. Lydon succumbed to an intra-abdominal hemorrhage resulting from complications during surgery. It was noted that anti-coagulation treatment, aimed at preventing a pulmonary thromboembolism, also contributed to her decline and eventual death.
The coroner emphasized the issue of restricted access to a patient’s medical records across healthcare facilities, underscoring the importance of seamless information sharing for optimal care. Efforts towards real-time access to patient records were acknowledged; however, the broader challenge of national data sharing remains unresolved.
The coroner’s narrative conclusion labeled Mrs. Lydon’s death as a case of neglect, prompting a Prevention of Future Deaths report released on April 21. Both Gateshead and South Tyneside NHS Trusts have been given 56 days to respond to the report, outlining corrective measures to prevent similar occurrences.
Concerns were also raised regarding communication protocols with Mrs. Lydon’s GP and prescription practices, emphasizing the need for improved coordination between primary and secondary care providers. Acknowledging the shortcomings in Mrs. Lydon’s care, medical directors from South Tyneside and Sunderland NHS Foundation Trust and Gateshead Health NHS Foundation Trust expressed condolences to her family and pledged to enhance patient care protocols for better outcomes.