Inquest Held Into Death Of Patient Following Gallbladder Operation at Royal Chesterfield Hospital

A family has called for lessons to be learned after a hospital admitted it ‘missed opportunities’ to diagnose a patient’s leaking bile duct in the days before his death.

Roy Debell died four days after undergoing keyhole surgery at Chesterfield Royal Hospital to remove his gallbladder.

Three days after his procedure, the 76-year-old, who was suffering increasing pain, underwent emergency exploratory surgery during which doctors found a leaking bile duct. He died in the early hours of the following day from multiple organ failure caused by leaking bile, an inquest heard.

Following his death Roy’s family instructed expert medical negligence lawyers at Irwin Mitchell to help investigate his care at the hands of the Royal Chesterfield Hospital NHS Foundation Trust.

The NHS Trust has written to Roy’s widow Shirley, of Chesterfield, saying its own internal investigation had “identified a number of missed opportunities by both nursing and junior medical staff to escalate Roy’s deteriorating condition and increasing pain.”

An inquest was also told that it “would have been appropriate to escalate concerns to a more senior doctor.”

In the letter Jane Brown, the Trust’s patient safety lead, offered her ‘sincere apologies’ and added that the care Roy received was “not in line with the Trust’s policies and procedures” and was “not the level of care we would expect or want for our patients.”

The Trust added that junior doctors were now notified of elective patient admissions in advance so they can ‘pre-order’ tests such as blood tests to “ensure they are completed in a timely manner.”

Expert Opinion

“Shirley and the rest of her family had a number of concerns about the care Roy received during his stay at Royal Chesterfield Hospital, particularly around his post-operative care.

“Sadly the Trust’s own internal investigation has endorsed some of those concerns, finding that there were failings in Roy’s care.

“These failings are extremely worrying. While nothing can bring Roy back it is now vital that the Trust learns lessons from his death so other families don’t have to suffer as Shirley and the rest of her family have.” Sinead Rollinson-Hayes - Associate Solicitor Advocate

Roy, a retired engineer was married to Shirley, aged 72, a retired secretary, for over 51 years. They had one child, Simon, aged 42.

Roy was originally admitted to A&E at Chesterfield Royal Hospital on 22 July, 2017, with abdominal pain and was diagnosed with gallstones. He underwent planned surgery to remove his gallbladder on 8 November.

After the operation Roy was advised that his bile duct had been cut but had been stitched up, Chesterfield Coroner’s Court was told.

However, Roy continued to be drowsy and was in pain. Shirley raised concerns with nurses about his condition on 10 November. He was seen by a junior doctor that evening and placed on a drip for dehydration, the hearing heard.

At 4.30am on 11 November Shirley received a phone call to say her husband’s condition had deteriorated. He underwent surgery where the leak was discovered. However, he suffered a heart attack because of multiple organ failure as his bile duct had been leaking during this time. He died in the early hours of 12 November, 2017.

Following the hearing Shirley, said: "Roy was everything to me, he was my soul mate and I still cannot believe he is no longer with me.

“We had so many more plans and hopes for the future and now these have been taken away from me.

“Seeing him in so much pain in hospital was heart-breaking. I knew there was something badly wrong but I just felt that the staff did not take my concerns seriously. It is difficult not to think that if the hospital had acted with more urgency Roy would still be here today.

“All I can hope for now is that Roy’s death is not in vain and the Trust ensures it implements its new procedures. I would not want any other family to suffer the feelings of anger, pain and loss that we have.”

An inquest at Chesterfield Coroner’s Court heard junior doctors had undergone further training about when to escalate concerns with Roy’s case used as a case study as to when this should happen.

Assistant Coroner Miss Kathryn Hayes recorded a narrative conclusion, highlighting failings in Roy’s care but said it was not possible to say whether earlier escalation of his treatment would have saved his life.

The Assistant Coroner considered making a Preventing Future Deaths Order, however, stopped short of doing so after hearing of the steps the Trust had made to improve the level of care provided, and the hospital saying it would be a ‘professional failure’ if improvements were not made within the next 6 to 12 months.”  

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