GP Missed Blood Test Results, Leading to Death

Stephen Rhodes, a 66-year-old man, died after a cardiac arrest because a GP surgery failed to identify abnormal results from a blood test taken on September 13, 2024. Rhodes had visited Quarry Bank Medical Centre with symptoms of shortness of breath. His blood work included a test for increased left atrial pressure, which returned a reading of 3473 – substantially higher than the normal level of less than 400 for his age group.

Despite the lab advising a special assessment and ultrasound within two weeks, the results were filed incorrectly. Coroner Zafar Siddique determined that this neglect contributed to Rhodes's death from hypertensive heart disease due to aortic stenosis. Siddique noted that an earlier cardiological referral could have led to timely treatment, possibly involving aortic valve replacement with a low surgical risk. The coroner expressed concern that similar errors could occur in the future and has issued a prevention of future deaths report to NHS England and the practice.

Since the incident, the laboratory has updated its reporting system to ensure abnormal results are clearly flagged on the first page. The coroner stated that had the aortic stenosis been diagnosed earlier, when it was symptomatic with heart failure, the mortality rate could have been as high as 50% within two years. Earlier intervention was deemed likely to have saved Rhodes's life.