Grieving Husband Calls For An End To A&E Gatekeeping By Unqualified Staff

Medical Negligence Lawyers Instructed By Husband To Investigate Wife's Care


Dave Grimshaw, Press Officer | 0114 274 4397

The heartbroken husband of a London woman who died from sepsis and multi organ failure following a four hour delay to treat her after she visited A&E when a cyst on her ovary ruptured has spoken out about the ‘nightmare’.

Madhumita Mandal (known as Maddie) was just 30-years-old when she died on 11th September 2013. She had a history of endometriosis and she was diagnosed with a cyst on her ovary which she was due to have removed but fell ill days before and died in hospital.

Her husband Prabhanjan Behera instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the care Maddie received at Croydon University Hospital, run by the Croydon Health Services NHS Trust and the circumstances in the days leading up to her death.

At an inquest today at Croydon Coroners Court, HM Coroner Lynch gave a narrative conclusion highlighting significant issues and saying there were missed opportunities which may have prevented her death.

The inquest heard how a private company was outsourced by the Clinical Commissioning Group to provide a gatekeeping service to decide on who was to be treated as a priority. At the time Maddie visited A&E the person making the decisions on priorities and timings was qualified as a mortgage advisor rather than a medical practitioner.

Expert Opinion
“This is an extremely tragic case where an otherwise fit and healthy young woman lost her life after a delay in treating her condition. Maddie’s family has been left heartbroken after losing her so suddenly and we hope that the inquest has gone some way to help them find answers as to the circumstances leading up to her death.

“Maddie was in a critical condition when she was taken to A&E at Croydon University Hospital and despite Prabhanjan repeatedly raising his concerns to staff about her condition and her medical history; she was not treated as a priority and instead faced a lengthy delay as her condition rapidly declined. When she was seen by doctors scans revealed internal bleeding but it was too late to save her life.

“We understand the NHS Trust is unhappy with the fact that non-medical staff are making decisions on the priorities and timings for the A&E walk-up patients and it is disappointing to hear of issues with commissioning groups such as this as this was a problem highlighted in the Francis Report following the Mid-Staffs Public Inquiry in 2013.

“Patient safety needs to be the number one priority for the NHS. Maddie’s husband is now seeking assurances that lessons will be learned from the errors in this case to ensure that delays such as this cannot happen again.”
Louise Forsyth, Associate

The two-day inquest heard that Maddie and her husband had been trying for a baby when the cyst was discovered; a couple of days before the surgery was scheduled Maddie felt unwell and was taken to A&E at Croydon University Hospital on 7th September.
Maddie was continuously vomiting and could not keep down any fluids. A nurse examined her initially asking whether she could be pregnant, but Prabhanjan explained her condition, that she had endometriosis and had a cyst and due to have surgery in a few days. 

She continued to deteriorate despite Prabhanjan repeatedly asking staff to help her. Maddie was eventually taken for a scan four hours later which suggested that she had internal bleeding.

She was taken into surgery to find the cause of the bleeding and after she had been in surgery for nearly four hours a gynaecologist came to see Prabhanjan to explain that they had found a cyst on her right ovary. They also found another cyst in her left ovary but as her condition was unstable they were unable to remove it. The doctor also told him that her heart had stopped beating for 30 seconds during the operation and she needed to be resuscitated. 

At 11:30 that evening Maddie was on a life support machine as her organs continued to fail. In the following days, her condition continued to deteriorate and doctors told her family that there was nothing more they could do to help her. Her life support machine was turned off on 11th September with her husband by her side.

Prabhanjan,38, said: “Losing Maddie has changed my life completely – I feel like I’ve lost everything and my world came crumbling down. I have been left absolutely devastated by this nightmare – we had everything to look forward to and were hoping to start a family of our own.

“I would like to thank the Coroner for carrying out a thorough investigation into Maddie’s death; I had so many questions as to why Maddie’s deteriorating condition was not taken seriously despite me continually raising my concerns. They were told about her medical history and her condition and still she was not treated as a priority.

“I feel that there were a number of occasions that if doctors had intervened and treated her sooner, she would still be with me today. Every second counts when you are in hospital and I feel that Maddie’s condition was not taken seriously enough to begin with. To have non-medical staff making these potentially life or death decisions seems to be unacceptable to me and I would hope that medically-qualified people will be making decisions in future.”