Martin Hill

In the circumstances it is my statutory duty to report to vou: _ (1) The abdominal X-ray report was not seen by ay doctor and all subsequent diagnoses were made without knowledge of its content (2) Although the doctor in A&E did not have had access to it at that time he stated that had he known of its content he would have referred the patient for surgical review and he would not have been discharged when he was_ (3) The 2 GPs who saw the deceased on the 22nd and 24th respectively stated that on the information had Mr Hill had been discharged with a diagnosis of constipation: Had been aware of the content of the X-ray report it would have raised the concerns which had to the level where they would have then arranged for Mr Hill s readmission to hospital Ellery the The The they thev they

(4) On the 2oth April there was radiological evidence of small bowel obstruction, according to the independent pathologist, most likely episodic Over the next 4 days it became progressively worse, described by the pathologist at PM as hugely distended. The prospects of successful intervention declined over the subsequent 4/5 days The report; when available, was not acted upon.

(5) An additional concern arose separate to this Mr Hill, when he was discharged on the 2oth April, had been prescribed medication. Mr Hill should have left the hospital with that medication but none was provided to him. It Is unlikely that its absence had any material effect in this case but it could in others, (6) For completeness, and it is an issue which arose in an earlier Inquest; no discharge summary was sent to the patient's GP. This appears to have been an exception to normal practice &d an indication was given at the Inquest that this issue has already been addressed. Confirmation of this is sought: