Medical Lawyers From Irwin Mitchell Urge NHS To Improve Systems After Catalogue Of Errors

A widow left distraught when her husband died following a catalogue of errors at a Cambridgeshire hospital has criticised the “disgraceful” standard of care her husband received.

53-year-old Allan Barratt, from March, in Cambridgeshire, died four days after undergoing hernia repair surgery at Peterborough City Hospital in June 2010. A report into his death lists 29 contributory factors, which include misreporting and failures to act on clear symptoms.

Although the surgeon perforated his bowel during the procedure – an issue which is included on the list of known complications following hernia repair surgery – doctors failed to spot the mistake for three days while Mr Barratt’s condition rapidly deteriorated.

Medical law specialists at Irwin Mitchell are urging hospital bosses to learn from the errors in this case. The firm is particularly concerned at the systemic nature of these mistakes, which raise concerns for the safety of other patients undergoing this surgery at this unit.

At an inquest into Mr Barratt’s death at Peterborough Coroner’s Court this week (22 August), Coroner Gordon Ryall returned a narrative verdict, concluding that Mr Barratt died from sepsis due to faecal peritonitis, as a consequence of an injury to the small bowel during the hernia repair surgery.

The hospital’s own internal investigation, conducted before the inquest, highlighted a series of major flaws in Mr Barratt’s treatment, including:

• Serious omissions in the medical records relating to Mr Barratt.
• Lack of communication between doctors, who each of whom “appeared to have worked in isolation.”
• Failures to act on concerns that Mr Barratt was in severe pain following surgery, something described as evidence of “substandard care.” 
• Failure to raise concerns that Mr Barratt had to be placed on an analgesic pump for pain relief. The report says that “this requirement should have raised alarm bells.”
• Apparent delays in contacting the surgical team to review the patient, during the working day when the team should have been available
• Failure to act on “grossly abnormal” results shown during observations of Mr Barratt in the days after surgery. 
• Delays in arranging a CT scan of Mr Barratt’s abdomen, which was then misreported causing a further delay of approximately 12 hours in treatment.

The report also states that if the bowel perforation had been identified at the time of surgery, or even in the two days following his operation, “it is likely” that Mr Barratt would have survived. Irwin Mitchell is seeking reassurances from the hospital that it has acted on recommendations made in its internal report.

Jenny Baker, a medical law specialist at Irwin Mitchell, said: “There were a series of serious failings in Mr Barratt’s care and this is extremely worrying for other patients. These were not just human errors but included gross systemic failings, which could potentially put other patients at risk.

“Inadvertent injury to the bowel is a recognised complication of hernia surgery. Our main concern is that nobody picked up on the clear signs that damage had been done during surgery, even thought it was obvious Mr Barratt was in great pain.

“Questions remain over record keeping, communication and reporting, and  this is inexcusable. The repeated failure to record visits and reviews with Mr Barratt are very worrying.

“It is vital that the hospital puts into place the recommendations made in its internal report, and those made again by the Coroner today. Patient safety has to be the utmost priority for the NHS and action must be taken to prevent others from suffering in the future.”

Janice Barratt, Allan’s widow, said: “Myself and the whole family have been devastated by Allan’s sudden and unexpected death.

“The level of care he received from the hospital was disgraceful, and the failure to recognise something was seriously wrong in the days following as his condition deteriorated is unacceptable.

“I phoned the hospital three times the day after his operation and was repeatedly told he was fine. When I phoned again the next day, I was told he had vomited and was quite ill. I then visited that evening and I was shocked by how bad the reality of his condition was. 

“Nothing can bring Allan back to us but we want lessons to be learnt for the future. At least then nobody else will have to suffer like we have.”

The Peterborough and Stamford Hospitals NHS Foundation Trust has already admitted liability in relation to a civil claim and is currently working to agree a settlement with Irwin Mitchell on behalf of the family.