‘Alarm Bells Should Have Been Ringing’ That Hospital Patient Could Have Complications, Inquest Hears
A family have called for lessons to be learned after an Inquest heard a delay in diagnosing a hospital patient’s leaking bowel resulted in his death from sepsis.
Simon Healey underwent “routine surgery” at the private Berkshire Independent Hospital after he was diagnosed with bowel cancer.
No complications were initially recorded. However, over the coming days his condition deteriorated, but no action to escalate his care was taken by either the nursing staff or his treating consultant, the hearing heard.
Six days after his operation, Simon, of Finchampstead, Berkshire, was diagnosed with a leaking bowel and sepsis. Despite surgery to repair the leak, the father-of-five’s condition continued to deteriorate. He died three days later from multiple organ failure, caused as a result of septic shock, the court was told
Following his death, Simon’s family instructed specialist medical negligence lawyers at Irwin Mitchell to investigate the events leading up to his death and support them through the Inquest process.
Simon’s family, including his Widow, Alison, have joined their legal team in calling for lessons to be learned.
It comes after an Inquest was told that three days before Simon’s leaking bowel was detected “alarm bells should have been ringing” for Mr Daniel McGrath, the surgeon who carried out the initial surgery, and that if Simon had undergone surgery earlier to repair his leak, he likely would have survived.
Expert Opinion“Alison and the rest of the family have been greatly affected by Simon’s death and are still struggling to come to terms with what has happened.
“They had a number of concerns about the events that unfolded following the initial surgery and sadly the inquest has validated those concerns.
“Simon’s case is a tragic reminder of what can happen when infections are not diagnosed promptly and patients do not receive the treatment they require in time.
“We hope that health professionals learn lessons from this case so other families don’t have to suffer the pain and anguish that Simon’s have, following his death.
“We will continue to support Alison and the rest of the family through this traumatic time.” Rebecca Brown - Senior Associate
Simon and Alison married in 2002 and the couple had a daughter and a son, aged 15 and 14. Simon had a son and a daughter, aged 34 and 30, as well as a 44-year-old stepson.
After turning 60 in January 2017, Simon was invited to take part in the bowel screening programme. Following routine investigations, he was diagnosed with bowel cancer in June 2017.
Reading Coroner’s Court was told that Simon had an appointment with Mr McGrath, a consultant surgeon, on 27 July, 2017, during which it was recommended he undergo a procedure called a right hemicolectomy, to remove the tumour.
The Coroner was informed that during his appointment with Mr McGrath, the possibility of Simon having the operation at a private hospital was discussed. Mr McGrath reassured Simon that the operation was routine, and, in the unlikely event of complications, he could be transferred from the private hospital to the Royal Berkshire Hospital, for specialist intensive care.
Simon underwent surgery at the privately-run Berkshire Independent Hospital on 1 August.
The following morning, Alison was contacted to say the operation had gone well. However, over the coming days Simon’s condition did not improve.
On Saturday, 5 August, Alison said she felt her husband was extremely ill. He was complaining of being in severe pain, was sweating and bloated.
The following day, Mr McGrath said Simon was showing signs of continued improvement, the court heard.
However, on 7 August, Simon was taken for an x-ray. It was believed he may have a leak in his bowel and was referred to the Royal Berkshire Hospital that night for a diagnostic CT scan. He underwent emergency surgery in the early hours of the following morning, in an attempt to repair the leak.
Following surgery, Alison was told her husband was extremely ill and had severe sepsis.
His condition continued to deteriorate. On 10 August, 2017, it was decided to take Simon to surgery in a final attempt to improve his condition. However, he died that afternoon.
Alison received a letter at the end of August 2017, from Ramsay Health Care UK, which runs the Berkshire Independent. The letter stated that on 4 August Simon was placed on a ‘sepsis pathway’ – a plan designed to reduce the risk of patients developing the infection. However, she had not been told her husband may have sepsis until he was transferred to the Royal Berkshire Hospital, the Inquest was told.
A report prepared by the Coroner’s expert, Professor John Scholefield, a Fellow of the Royal College of Surgeons of England and of Edinburgh, was presented to the court.
He said that the type of leak Simon had was the “most feared complication after bowel surgery”, therefore, surgeons, during post-operative examinations, should be suspicious that a patient could have developed a leak.
It seemed Mr McGrath was not “particularly concerned” about his patient on 4 August, the report said. Professor Scholefield said Simon’s symptoms on 4 August were indicative of sepsis, and Mr McGrath should have considered a leak in Simon’s bowel as a result.
He concluded that “alarm bells” should have been ringing on 4 August that Simon had a leaking bowel and that a delay in diagnosing the leak “probably resulted” in Simon’s death. If he had undergone corrective surgery as late as 6 August ,Simon’s situation was probably “salvageable”.
Coroner Heidi Connor recorded a narrative verdict in which she concluded, that in all likelihood, had Simon been adequately reviewed when he began to deteriorate on 4 August, he would have been transferred to the Royal Berkshire Hospital, undergone a CT scan to diagnosis the leak, and would have undergone treatment to save his life.
The coroner was concerned by the care provided to Simon by Berkshire Independent Hospital, including their record keeping and observations. She requested that Ramsey Healthcare prepare a Prevention of Future Death Report, to examine Simon’s care while at the private hospital.
After the hearing Alison said: “Simon was a fit and healthy man for his age, and to see him deteriorate so quickly over such a short period of time was extremely distressing.
“During Simon’s illness, I felt helpless and ignored. When I brought up concerns that he was not recovering from his surgery, or that he was deteriorating, I felt like I was being fobbed off with reassurances that different people recovered at different rates.
“I had never been told that there was a suspicion of sepsis and was not warned that Simon was seriously ill until after he was transferred to Royal Berkshire Hospital. Had sepsis been mentioned earlier, I would have fought to make sure that Simon was transferred sooner, instead I placed my trust in the medical staff trained to care for Simon.
“It is difficult not to think if Simon had been transferred earlier he would still be here today.
“All our family can hope for now is that Simon’s death is not totally vain. We are pleased that the coroner recognised our concerns and seriousness of what happened to Simon and requested a Prevention of Future Death Report.
“We hope that lessons are learned about how important it is for infections to be diagnosed as soon as possible. We would not wish the pain and suffering we continue to face every day on anyone.”