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Fatal Accident Inquiry into the Death of Marion Bellfield, Sheriff Peter Braid, Kirkaldy Sheriff Court, 28 April 2011


In terms of section 6(1)(a) of the Fatal Accidents and Sudden Deaths Inquiry (Scotland) Act 1976, the sheriff found that Mrs Marion Bellfield (d.o.b 22/3/49) died at 22.08 hours on 15th February 2009 at her home at 82 Chapelhill, Kirkcaldy, Fife. In terms of section 6(1)(b), the causes of death were (a) suppurative mediastanitis and pleuritis (b) endoscopic oesophogeal perforation/rupture and (c) oeosphogeal squamous carcinoma. Formal determinations were made under section 6(1)(c), (d) and (e).
On 13th February 2009 Mrs Bellfield attended the endoscopy unit at Victoria Hospital, Kirkcaldy in order to undergo an upper gastrointestinal endoscopy. It was suspected that a cancerous tumour might be present, however previous biopsy samples had tested negative. Mrs Bellfield experienced discomfort during the procedure. No evidence of cancer was found. Following the procedure the deceased developed pain in her lower abdomen and her blood pressure dropped. This was attributed to Mrs Bellfield swallowing air or pulling a muscle. An x-ray was carried out which showed no signs of air leakage. The deceased was then discharged. Her condition deteriorated over the next few days and she was attended by two different GPs on 13th and 15th February. Mrs Bellfield collapsed in her house on the evening of 15th February and was pronounced dead at 10.08pm.
In respect of subsection (c) the carrying out of a CT scan as the first line of investigation was a reasonable precaution which might have prevented the death of Mrs Bellfield. In respect of subsection (d) there were no defects in any system of working which contributed to the death.
In respect of subsection (e), relevant facts were: that Mrs Bellfield was diagnosed post-mortem with carcinoma of the oesophagus; that her symptoms were atypical of perforation, making the perforation more difficult to diagnose; that she received adequate advice on her discharge from hospital; and that neither of the GPs who attended on 13th and 15th February 2009 had sufficient knowledge and experience of oesophageal perforations to enable them to diagnose Mrs Bellfield's perforation.