A hospital has admitted being liable for the death of a 42-year-old patient after medical staff failed to check the results of an urgent MRI scan for three days – completely missing a brain abscess from which he died.
Staff on weekend duty at the Morriston Hospital in Swansea allowed Colin Mayes’ condition to rapidly deteriorate following his admission, as they were completely unaware he needed urgent treatment.
They only checked the results of the MRI scan and realised their error the day after he died.
Mr Mayes, who had no previous history of serious illness and was the sole carer for his wife Christine, had been sent to hospital by his GP with a suspected stroke after suffering headaches and weakness for a number of days.
A serious incident report (SIR), carried out by the Abertawe Bro Morgannwg University Health Board, which runs the hospital, highlighted a lack of communication between medical teams as being the reason for the MRI scan being left unchecked.
It said the radiologist assumed medical teams would be looking for the results to check them on the hospital’s computer system, and therefore did not physically inform them of her findings and recommendation to carry out an urgent neurosurgical review.
As a result, medical teams were left unaware of the findings and treated Mr Mayes with a ‘lack of urgency’ and considered him to be of ‘low priority’, despite the scan showing the brain abscess, something which kills about one in 10 with treatment, but is nearly always fatal without.
The SIR said there had been poor communication at both consultant and trainee levels, and between medical and radiology doctors and nursing staff and junior doctors.
The confusion led to signs of infection and progressive brain failure being ‘misinterpreted as signs of nicotine withdrawal’, and even resulted in the wrong cause of death being recorded on Mr Mayes’ death certificate.
Now, following legal action through medical negligence specialists Neil Hudgell Solicitors, the Trust has agreed to compensate Mr Mayes’ widow, offering an ‘unreserved apology’ and agreeing to pay her bereavement damages to compensate for her loss.
Solicitor Hayley Collinson said: “The errors made in this case are completely unacceptable. There can be no excuse at all for their failings at this hospital, and these failings have come at the ultimate cost.
“For a hospital to carry out an MRI scan on a patient, and then simply fail to follow-up on the results, is beyond shocking.
“Mr Mayes was left with his condition deteriorating over the weekend and without the treatment he needed because medical teams simply failed to communicate with one another about the seriousness of his situation.
“Mrs Mayes says she will never recover from this and that is quite understandable. Her husband was badly let down by the staff at Morriston Hospital. Even without knowing the details of his MRI scan results, staff still failed to act on his deteriorating condition, something which also highlights a concerning lack of care towards patients.”
Mrs Mayes, 50, says losing the love of her life is something she will never recover from.
“We were soulmates, and were meant to be together, but he was taken away from me by doctors failing to do the very basics of their job. How on earth can a hospital take an MRI scan on a patient and not look at the results for three days? It is appalling,” she said.
“If the doctors had done what they should have he would have been rushed to Cardiff Hospital for emergency treatment. Instead he was left, with his condition worsening over the weekend, and simply allowed to die.”
The couple had found love over the Internet in 2010, with Mr Mayes travelling down to Wales from his home in Arbroath, Scotland to meet for the first time. Mrs Mayes says they immediately fell for one another and married the following year.
She said: “He agreed to come and see me in Wales and he never went back. We’d already agreed to get married before he came to see me as we just clicked, and we had a big wedding with all of our family and friends there.”
Mrs Mayes says her husband had never previously suffered from any serious illnesses and was an active man who liked to get out and about and potter in the garden, as well as acting as her full-time carer due to her suffering from severe arthritis.
“It’s heart-breaking to have lost the love of your life in this way, so suddenly, and I think about it every day,” she added.
“He had been suffering from some headaches and feeling weak and so went to the doctors. I could never imagine he’d go into hospital and not come out. What good is an apology when I have lost the man I loved, and the man who loved me? We had so much in common, it really felt we were meant to be together, soulmates.
“I thought we’d be together for ever. I can’t move on with my life now. It stopped the day he died. I’ll never look to be in another relationship as Colin was my one true love.”
The SIR concluded: “The correct diagnosis should have been made shortly after admission by using a combination of clinical features, blood results and radiology images. This information was never brought together until after the patient had died.”
As a result of the case, 10 recommendations were made to improve care at the hospital, including the introduction of a ‘fail-safe system’ in which urgent findings are communicated to the relevant medical teams, and measures to ensure better communication between senior ward-based clinicians and radiologists.