NHS Trust Admits Failings That Led To Death Of Dad Following Routine Operation

Expert Lawyers Call On Trust To Prove Lessons Have Been Learnt

12.05.2014

The distraught widow of a dad-of-three who died from heart failure following a routine knee replacement operation has spoken out after the NHS Trust responsible for her husband’s death admitted that mistakes were made.

Expert evidence commissioned by medical law experts at Irwin Mitchell found Robert Collett would in all likelihood still be alive today if staff at the Royal Orthopaedic Hospital in Birmingham discontinued knee surgery when he started showing signs of cardiac distress in theatre. Frustratingly, the 62-year-old had been assessed at the same hospital earlier that week where an ECG showed an abnormal heart monitor reading.

Instead, on the 9th February 2011, doctors continued to perform a total knee replacement procedure under spinal anaesthetic, despite Robert’s recent abnormal ECG and his complaints of chest pain in the anaesthetic room.

Robert, from Halesowen, suffered a cardiac arrest and died just hours after the operation and after being transferred to City Hospital leaving behind his devastated wife Angela, his three children and two grandchildren.

Specialist medical negligence lawyers at Irwin Mitchell have now secured the family an admission of responsibility from The Royal Orthopaedic Hospital NHS Foundation Trust who confirmed in writing that “had the procedure therefore been discontinued when the Deceased first developed chest pain it is likely that the arrhythmia would have been avoided and the cardiac arrest would not have occurred”.

Although Angela remains angry at receiving no apology for her ‘needless’ loss and says she is not confident that the same mistakes will not happen again, she is pleased that the NHS Trust has finally owned up to their mistakes. She would encourage anyone in similar tragic circumstances not to give up hope of finding answers.

Last summer, a Coroner at Birmingham Coroner’s Court criticised the anaesthetic records and recommended that the hospital use the case as an example in lessons to all of their staff on the importance of competent record keeping.

An independent review carried out by The Royal College of Anaesthetists after Robert’s death 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 medical law expert at Irwin Mitchell’s Birmingham office representing the family, said: “There are clear guidelines in place on the importance of assessing a patient’s pre and ongoing-surgery condition so there is no excuse for all of these points being noted as poor in the independent review that was carried out following Robert’s death.

“The evidence we obtained from medical experts was clear – a complaint of chest pain should have led to the surgery being stopped.

“Instead, a catalogue of failings meant Mr Collett died a completely preventable death which has obviously been incredibly hard for his family to come to terms with.

“Whilst we welcome the admission of liability from the Trust we remain concerned at the lack of reassurance that lessons have been learnt and improvements made to protect patient safety in future. The Collett’s and future patients deserve confirmation that every possible step has been taken 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.

HM Coroner heard how 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 worked at the Royal Orthopaedic Hospital at the time of her husband’s death but has since left, 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 transferred to City Hospital where they could treat him. 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 a cardiac arrest and there was nothing anybody could do, he had died.

“Robert’s death has left a huge hole in all of our lives. Had they taken notice of his complaints of chest pain and carried out the necessary investigations he may still be here today.  Whilst I am relieved the Trust has admitted liability, it won’t bring him back”

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