Widow Of Man Who Died After Routine Knee Operation Speaks Of Inquest Heartbreak

Medical Law Experts Demand Answers From Hospital Trust

19.07.2012

The  distraught widow of a dad-of-three who died from heart failure after a routine knee replacement operation said despite an inquest into his death she is still left with unanswered questions about why there were failings in his care due to medical staffs’ ‘extremely poor’ record keeping.

Angela Collett, 52, was devastated by the ‘needless’ death of her husband Robert on 9 February 2011 at the Royal Orthopaedic Hospital in Birmingham, where she used to work as a clinical nurse specialist, and  has launched a battle for justice against her former employers with help of medical law experts at Irwin Mitchell.

Following a four-day inquest at Birmingham Coroners Court, specialist medical lawyers at the firm say they are deeply concerned to hear about a series of failings by the anaesthetist caring for Robert, who died aged 62, following knee surgery. They are now demanding the Trust provide answers about exactly what went wrong.

The court heard how some clinicians had heard Robert complaining of feeling unwell before the surgery and that he had chest pains. However, the surgery proceeded and the Court was told how Robert’s condition then deteriorated further whilst it was taking place.

HM Coroner Aiden Cotter today (19 July) recorded a narrative verdict criticising the anaesthetic records and suggesting the Royal Orthopaedic Hospital use them as an example in lessons to all staff in terms of competent record-keeping.

The coroner heard an independent review carried out by The Royal College Of Anaesthetists after Robert’s death which found:
• There was poor communication between the pre-operative assessment clinic and anaesthetists;
• The standard of pre-operative assessment was poor and lacked physical examination;
• There was poor team-working with failures of communication between all members of the anaesthetic, surgical and theatre teams;
• The leadership by the senior anaesthetist was poor;
• Record keeping was extremely poor – proved by missing documentation of basic observations on the anaesthetic chart and transfer chart;
• Staff failed to adhere to hospital and national policies on the transfer of Robert to another hospital.

Laura Ralfe, a specialist medical lawyer at Irwin Mitchell’s Birmingham office representing the family, said: “The failings found by The Royal College Of Anaesthetists are completely unacceptable and the hospital Trust must give answers about why such a breakdown in communication by the anaesthetist to surgeons, poor record keeping and failures to follow policies were allowed to happen.

“More care should have been taken to assess Robert’s pre and ongoing-surgery condition to see if he was fit enough for the operation to go ahead.

“There are clear guidelines in place on the importance of each of these points so there is no excuse for all of these being noted as poor by the independent review. The Trust must provide answers about why this was the case and they must show that improvements have been made to prevent the same mistakes from happening again.”

Robert, a part-time driver, had been suffering knee pain and in early 2010 his GP referred him to the outpatients department at the Royal Orthopaedic Hospital, where doctors examined his knee and concluded he would need a complete knee replacement.
A decision was made for Robert to stay awake during his surgery and it went ahead despite some of the treating clinicians hearing Robert complaining of chest pains and feeling unwell beforehand.

The inquest heard Robert was coughing as the operation began and the anaesthetist noticed his oxygen levels had dropped. As he struggled to breathe, crackling noises were heard through the stethoscope which was fluid leaking into his lungs, but the surgery continued.

Angela, who has since left her job at the Royal Orthopaedic Hospital said: “I went to the theatre recovery room on my lunch break and it was unusually quiet. I remember asking two nurses where my husband was and when I said his name was Robert Collett, their faces just dropped.

I was told he would be taken to City Hospital where they could treat him.
Angela added: “Because of my job I knew the policy was that doctors can only transfer patients once they are stable so I hoped that was the case. But when I arrived I was taken straight into the relative’s room and was told Robert had suffered another cardiac arrest and there was nothing anybody could do – he had died.

“I felt like my heart was being ripped out it was such a huge shock. We were looking forward to many more years together and as far as we were concerned it was routine surgery. I became distraught to learn shortly thereafter of the warning signs during the surgery that something wasn’t right but that no one seemed to react to it.

“We had booked a safari holiday for October and Robert was focused on being able to walk a bit better so he could really enjoy the trip but all our plans were ruined. As I have a medical background I knew there were clear failures in Robert’s care but the inquest has confirmed my worst fears – he was let down by medical staff when he needed help most.

“I’ve since left my job at the hospital as it was just too painful to work there. Despite the inquest I still have questions about why the surgery went ahead in the first place when Robert was showing clear signs of being unwell before and during the operation.”

Laura Ralfe added: “Mrs Collett has shown extreme dignity and bravery throughout the inquest which has been both shocking and harrowing for her. She still has unanswered questions and the Trust must now provide answers about what happened to Robert so she can finally come to terms with his death.”