'Lessons Must Be Learnt' From Incident, Experts Urge

Medical law experts at Irwin Mitchell have welcomed changes to nursing care made by a Yorkshire hospital after a woman died from multi-organ failure following surgery on suspected pancreatic cancer.

Christine Johnson died on 21 April 2010 aged 58 years at St James’ University Hospital, Leeds. An inquest into her death at Leeds Coroner’s Court found that she died as a result of multi-organ failure as a result of complications arising from surgery.

Mrs Johnson was discharged following surgery on 8 March but was re-admitted on 21 March after her condition worsened. During the next month of care there were problems with drainage of fluid from her chest. No one noticed kinks and blockages for around 34 hours and there was also a lack of detailed nursing notes related to the checking of the drains.

The Hospital says it has now improved procedures to the checks and notes staff make on drainages a move welcomed by medical law experts at Irwin Mitchell representing the family who say that lessons need to be learned to prevent similar cases.

Anna Bosley, a medical law specialist at law firm Irwin Mitchell, said: “Christine’s death left the family devastated. Mrs Johnson underwent major surgery which was successful but she developed complications and her condition deteriorated until her death two months later.

“The inquest was a very thorough investigation of the clinical aspects of Christine's treatment and care and provided answers that the family had been seeking. It is clear that Christine was a very unlucky woman whose recovery was compromised by a multitude of complications. There were some aspects of her care that were far from satisfactory but we hope that lessons have been learned from this. We welcome the fact that the hospital has made changes and hope that this ensures a higher standard of patient care in the future.”

Mrs Johnson underwent surgery for suspected pancreatic cancer at the hospital in February 2010. The operation was successful although Mrs Johnson was found not to have cancer. She was discharged on 8 March but her condition deteriorated and she was re-admitted on 21 March with a suspected wound infection. Mrs Johnson continued to deteriorate. She was returned to theatre to clean the wound but developed further complications and on 16 April her right leg was amputated above the knee.

She suffered from further illness including internal bleeding but was too sick for surgery and sadly died on 21 April. The coroner Mr David Hinchliff recorded a narrative verdict saying her death was a result of “multi-organ failure due to a pancreatic leak which was a complication arising from her original procedure”.

Christine’s sister Jennifer Banks, from Undercliffe, Bradford said: “We welcome the findings of the inquest which has given us some answers into how Christine died. Nothing can bring Christine back however we remain concerned over the level of care she received. It was clear to us that her condition was getting worse. We just hope that lessons are learned from this so no one has to go through the same situation in future.”