THE mum of a Pembroke writer desperately pleaded with a doctor’s surgery for her to be treated at home to no avail, just days before she died of a ruptured bladder.

Kerry Jane Elsdon, 57, of 15 Main Street, Pembroke, died at home on June 11 of this year, an inquest heard on December 12.

Kerry Jane Elsdon, known as KJ, died of urosepsis, where a urinary tract infection spreads to the bloodstream, and a ruptured bladder, and large fibroid.

Coroner Mark Layton, said, on June 4, three frantic calls were made to the Pembroke Dock Argyle Street surgery by both Ms Elsdon and her mother, Valerie, transcripts of which were read out.

The first call, by Ms Elsdon, stated she was “pretty much” bathroom-bound after suffering cystitis from “a really bad kidney infection”.

She was told by the receptionist, following consultation with doctors, the surgery didn’t send out GPs on home visits unless people were housebound or terminally ill.

She was sitting in a puddle of bloody urine, hadn’t eaten for two days, and had no transport, she told a receptionist.

She was offered, and reluctantly accepted, a ‘sit and wait’ appointment for 3.30 that day, despite not being able to get to the surgery.

The second call was made by 83-year-old widow Mrs Elsdon.

She said: “I’m pleading with you to get a house call, she can’t make it to the surgery, she’s leaking, we haven’t got transport; I’m just pleading with you.”

The home visit policy was repeated.

Mrs Elsdon made a further call, speaking to the duty manager.

The sit and wait appointment was cancelled by Mrs Elsdon as she didn’t think her daughter was well enough to attend.

Mrs Elsdon said she had “no idea what we’ll do now”.

On June 9, the practice’s out-of-hours service was contacted for antibiotics.

On June 10, Ms Elsdon collapsed on the bathroom floor at her home. Paramedics and police were called, but Ms Elsdon was declared to have passed away shortly after midnight on June 11.

Valerie Elsdon told the inquest: “She was definitely housebound, she couldn’t have got in to a taxi, she was not in a fit state, she was almost in a state of semi-collapse.

“She was housebound; she was sitting in a pool of bloody urine, it was absolutely horrible.

“Sepsis has had a high profile recently; if I thought it could’ve been sepsis why wouldn’t the medics think it could’ve been sepsis?

“She was seriously unwell; she was badly let down, we’ve never bothered doctors for house calls or anything like that.”

Argyle GP partner Dr Jennifer Boyce said the surgery was “shocked and saddened” to learn of Ms Elsdon’s death, with her only involvement on the day when the request for a home visit was made.

She told the inquest: “I was just getting second-hand information at this time. I was following practice protocol, I was seeing patients; it was presented by staff as a transport issue; a logistical issue rather than a clinical issue.”

The inquest heard the third request was dealt with by the duty manager, who had explained the home visit policy.

On June 9, no complaint of fever, vomiting or loin pain was received at that time, Dr Boyce said.

Mr Layton said: “A call was made and only part of the information was passed on to Dr Boyce. On the basis of incomplete information, it was decided not to make a home visit."

He told Dr Boyce: "Had a full picture been taken I think that yourself would’ve taken a different view and made a home visit.”

A report by independent expert Dr James Burton said it was unclear what information the receptionist had passed on the doctors, but stating Ms Elsdon would have to come in was “effectively refusing a home visit, giving Ms Elsdon no choice”.

The report went on to say: “On June 4, in my opinion, a doctor should’ve spoken to Ms Elsdon or her mother.”

Giving evidence by video link, critical care consultant Professor Peter Andrews said it was difficult to know with any degree of certainty whether Miss Elsdon’s bladder had already ruptured on June 4.

Mr Layton said: “What was recorded in the notes was not representative of the true picture; either not fully recorded or not enough questions were asked.”

The inquest heard the surgery had already change the protocols for dealing with similar cases.

Giving a narrative conclusion in the death of Ms Elsdon, Coroner Mark Layton recorded the three amended causes of death, as recommended by Professor Peter Andrews, adding: “Kerry Jane Elsdon died at her home address on June 11 from urosepsis, following a spontaneous bladder rupture.”

He told Mrs Elsdon: “Hopefully some positive change will come about; I appreciate Mrs Elsdon that will not change what has happened to you, but may change things for other people.”