Fatal ulcer patient was sent home by doctor at Walsall Manor Hospital

Carl Barker, aged 41, was found dead at his home in Willenhall on February 9, 2010.

Mr Barker, a single man who lived in Parkes Street, Rose Hill, went to the Manor complaining of severe abdominal pain and being unable to pass urine on February 5.

The hearing was told there had been a failure by a former A&E doctor Imran Yousef to interpret the findings of Mr Barker's observations including that he had low blood pressure and had blacked out. It was also said the doctor had failed to record details of his examination of the patient. Mr Barker was diagnosed with gastritis and was given an analgesic and pain relief then sent home.

Cause of death at the inquest was given as shock and a bleeding ulcer.

A report by independent consultant, Dr Alistair Makin stated: "There are signs of failings in the management of Mr Barker. Dr Yousef failed to interpret his clinical findings of the abnormal observations and failed to organise appropriate investigations for a patient presenting with a collapse and low blood pressure and a fast heart rate.

"He should have had further investigation, treatment and hospital admission.

"In my opinion the management of Carl Barker falls well below that what should have been expected in these circumstances.

"I think the actions of Dr Yousef do amount to neglect."

Giving evidence at the hearing held in Smethwick, Dr Yousef, now a GP, said it had been a busy morning in A&E.

"I did suggest to the patient that that the problem was either gastritis or an ulcer. I suggested that he goes back to see his GP," he said.

Also giving evidence, Walsall Manor Hospital senior sister for A&E Lucy Smith, a staff nurse at the time, said she could not recall exactly what happened, but that she booked Mr Barker's tests when he arrived in the unit.

She said since his death the trust had introduced a score chart system and changed the design of cards used for staff to record the results of patient observations, which was working well.

Assistant Black Country Coroner Dr Andrew Thompson said he will write to all Clinical Commissioning Groups in the area about how information is shared after it emerged that the results of earlier tests booked by Mr Barker's GP, Dr Shadia Abdalla, were at New Cross Hospital, in Wolverhampton.

He recorded a conclusion that Mr Barker died of a natural cause contributed to by neglect through a failure to manage appropriately the abnormal findings from the assessment in A&E.