A disabled man died within hours of being allowed to leave A&E with without blood tests or a proper diagnosis.
Bill Longshaw died less than 24 hours after he was released from an emergency department in Swindon.
The 22-year-old from Heaton Norris, Stockport was born with D-2-hydroxyglutaric aciduria, a rare condition that causes progressive damage to the brain and affects muscle tone, speech, vision and memory, Manchester Evening News reported.
He had gone to the Great Western Hospital after having sudden abdominal pain and throwing up on a car journey.
Billy was assessed by a junior doctor in A&E who found everything to be normal.
In fact, Billy was suffering with ‘sigmoid volvulus’ - a twisted intestine which would quickly turn fatal.
Now a probe into his death has raised questions about the failure to diagnose Billy, who had significant learning difficulties.
Speaking at the pre-inquest hearing in July last year, his mum Caroline Bird, said: “He loved riding his bike. He was a character, he was funny, he was over six foot but he was still our baby."
She said she had a record of achievements for Billy, which showed off all he could do and said: "He made the best of his life."
In a report to prevent future deaths written after the inquest, Chris Morris, area coroner for Manchester South, raised concerns about the hospital’s failure to diagnosis the fatal condition.
He said Billy had been allowed to leave 'without basic blood tests being taken, any diagnosis being made, or serious abdominal pathology being fully excluded'.
He said that the sigmoid volvulus which led to Mr Longshaw’s death was likely present when he was assessed.
Billy had discharged himself just hours before he died.
In the report, Mr Morris said Billy should not have been allowed to leave and that junior doctors needed ‘adequate’ training on the Mental Capacity Act.
He said that there was a ‘missed opportunity’ to consider issues surrounding patients with significant learning difficulties discharging themselves from hospital, adding that the process used in this scenario was ‘obviously flawed’.
Mr Morris concluded that Billy died of acute bowel obstruction, a twisted intestine and heart problems brought on by his pre-existing condition.
A spokesperson for Great Western Hospitals NHS Foundation Trust in Swindon said: “We would like to offer our sincere condolences to Mr Longshaw’s family following his sad death.
"We have reviewed our procedures and have put extra measures in place to safeguard patients from being prematurely discharged.
"We provide our staff with training on how to support patients with learning disabilities or other complex needs and we are looking at ways to improve this."
