Pensioner died days after being wrongly discharged from hospital

NHS Fife were found to have wrongly discharged Derek Cowan after a fatal accident inquiry was held into his death.

Pensioner died days after being wrongly discharged from Victoria Hospital in Kirkcaldy © Google Maps 2023

A health board has apologised to the family of a pensioner who died days after being wrongly discharged from hospital.

NHS Fife were found to have wrongly discharged Derek Cowan after a fatal accident inquiry was held at Kirkcaldy Sheriff Court.

The 78-year-old was admitted to Victoria Hospital in Kirkcaldy in August 2019 after complaining about pain in his leg.

Mr Cowan, who also suffered from a range of medical conditions including Alzheimer’s, epilepsy and high blood pressure, was kept in hospital for treatment and tests.

Results indicated that he an acute kidney injury, but a “communication failure” led to the pensioner being discharged and returned to his care home seven days later.

He was readmitted to the hospital with dehydration four days later where blood samples revealed an infection and “significantly raised” sodium levels.

Mr Cowan was placed in palliative care before passing away on August 23, 2019.

Sheriff Elizabeth McFarlane has ruled that Mr Cowan should have been referred to a scheme known as Hospital@Home, which would have allowed blood samples to be taken and fluid levels monitored.

She said the process of discharge was “defective” and there was a “breakdown in communication” between staff at the hospital and care home.

NHS bosses told the inquiry their practices had already changed in the aftermath of Mr Cowan’s death and no formal recommendations were made by the sheriff.

Sheriff McFarlane said: “Four clinicians were unable to give a comprehensive or cohesive account of who was ultimately responsible for Mr Cowan’s care or who was ultimately responsible for authorising his discharge.

“All of the evidence around the discharge process points to a process which lacked checks and balances, accountability and formality.

“This contributed to the discharge of a patient who was not fit for discharge and which ultimately led to his untimely death.

“The evidence about the lack of proper communication and a proper, robust system in place for the discharge of Mr Cowan is pretty overwhelming.

“There were so many areas of confusion that it is not surprising the system failed.

“Having determined that not discharging Mr Cowan on August 15, 2019, was a precaution that could have reasonably avoided his death, I have no difficulty in finding that these defects in the discharge process contributed to that wrongful discharge and therefore contributed to his death.”

His partner, Linda Ballingall, received an apology from the health board after she made a formal complaint about his treatment.

Dr Christopher McKenna, medical director with NHS Fife, said: “On behalf of NHS Fife, I would like to apologise to Mr Cowan’s family and extend our most sincere condolences to them.

“Sheriff McFarlane made no recommendations in her report, noting the board had already taken a number of actions to improve its discharge processes following an internal investigation.”