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Dawn Liddell, 42, had brain haemorrhage inquest hears
A YORK mum died after doctors missed a string of opportunities to diagnose her brain haemorrhage, an inquest has heard.
Dawn Liddell, 42, of Wenham Lane, Foxwood, went to her GP and twice attended York Hospital complaining of a very severe headache.
She was sent home with a suspected tension headache on the first occasion and on the second – despite repeated requests by doctors – was not given a CT scan for 19 hours after her arrival.
By the time the scan showed she had a brain haemorrhage, it was too late to save her life, York Coroner’s Court heard.
York Hospital has accepted that with the right care Dawn was unlikely to have died and has paid compensation to her son, Jordan.
Phill Liddell, Dawn’s brother, told the court he could not understand the delays in diagnosis when there was a family history of brain haemorrhages.
“I said to the doctor, ‘she is having a brain haemorrhage’. I said ‘She will leave here in a body bag’,” he said of when he saw the condition of his sister on the morning of her death.
After believing an insect bite had caused her headache, Dawn went to see her GP in August 2008 and on September 4, attended the hospital with symptoms including a severe headache and sensitivity to light.
She was seen by Dr Soumaya Nasser, who told the court she suspected she had a tension headache or problems with her sinuses. When she reacted well to painkillers and tested negative for another condition she was sent home.
After collapsing and having a seizure at the Five Lions pub, Dawn arrived at York Hospital at 8.25pm on September 8, but was not given a CT scan until 3.30pm the next day, despite numerous requests. Her condition had deteriorated very sharply and she died that evening of a brain haemorrhage caused by the rupture of an artery aneurysm.
There were four occasions when an opportunity was missed to give Dawn a CT scan, which would have meant she could have had an operation giving her the “best chance” of survival, a serious untoward incident report by York Hospital found.
Chances were missed when she visited her GP, in A&E on September 4, when she went back to hospital on September 8 and on the morning of September 9.
Recording that she died of natural causes, coroner Donald Coverdale said: “It’s not clear why the scan took so many hours to carry out. It has been suggested there may have been problems with the equipment.
“One hopes the lessons learned – and indeed lessons must be learned – have been followed up.”
Speaking after the inquest, Mr Liddell said: “I know the doctors involved didn’t leave the house in the morning and intend for this to happen, but a mistake has caused the death of my sister.
“It’s as if no-one has got any responsibility for what they are doing.”
A spokesperson for York Teaching Hospital NHS Foundation Trust said: “We are sorry for the circumstances surrounding Dawn’s death, and once again extend our condolences to her family.
“This was investigated by the Trust and we accept that there are things we should have done differently.
“As a result of our investigation recommendations were made and measures have been put in place to try to prevent this being repeated.”