Husband Joins Irwin Mitchell In Calling For Lessons To Be Learned

The husband of a hospital patient left in a permanent vegetative state after suffering a post-operative brain injury has called for lessons to be learned after an NHS Trust admitted liability for her death. 

Michelle Ginsburg-Smith was starved of oxygen for around 10 minutes when there was a delay in keeping her airway open when she suffered a blood clot after undergoing surgery to remove her thyroid.

Junior doctors and nurses had not been told what to do in case Michelle suffered a rare post-operative complication. They had not received training to deal with such an emergency and a ‘thyroid emergency box’, containing equipment which may have prompted staff on what to do in case of an emergency was not available, an NHS investigation found.

It added there was also a five minute delay in a specialist resuscitation team reaching the 50-year-old because it had not been told which ward at Oxford’s Churchill Hospital she was on.

Michelle died seven months after the surgery. Following agreement between her family and doctors that she would not want to be artificially fed, a High Court Judge ruled her life support could be withdrawn.

Following her death, her husband Mark, 56, instructed expert medical negligence lawyers at Irwin Mitchell to investigate the care Michelle received from Oxford University Hospitals NHS Foundation Trust, which runs Churchill Hospital.

The Trust admitted there was “a negligent failure” in “recognising and appropriately treating” Michelle’s post-operative blood clot which resulted in her brain injury and subsequent death on 28 February this year.

Rosamund Rhodes-Kemp, Oxfordshire assistant coroner, recorded a narrative verdict. She recommended that thyroid emergency boxes are renamed ‘Shelley boxes’ in Michelle’s memory to help remind medical staff of the importance of the boxes. 

Following the inquest Mark has joined his legal team at Irwin Mitchell in calling on Oxford University Hospitals NHS Foundation Trust to ensure it learns lessons from Michelle’s case.

Expert Opinion

“This is a truly heart-breaking case which has had a tremendous impact on Mark and the rest of the family.

“For more than a year Mark and the rest of the family have had a number of concerns and it has now been established that there was serious failings in the care Michelle received.

“While nothing will ever make up for Michelle’s death and the pain her family have been left to face, we are pleased that the Hospital Trust has admitted liability.

“We urge the Trust to ensure it learns lessons and ensures staff adhere to guidelines the Trust itself has introduced following Michelle’s death, so others are not left to face the pain and anguish that Mark and his family have.” Emma Rush - Partner

Find out more about Irwin Mitchell's expertise in handling medical negligence cases 

Michelle, and Mark, lived in Temple Cowley, Oxford, and had been married for 10 years. Michelle was a senior catering manager, most recently for Krispy Kreme doughnuts, and Mark has worked as a social worker and trainer.

Michelle went into The Churchill Hospital on 13 July, 2017, for the operation. Following around four hours on a post-operative recovery ward, she was transferred to a gastrointestinal ward at around 11.15pm because there were no beds available on the head and neck ward that treats patients following a thyroidectomy.

Just after 1.40am on 14 July Michelle started having trouble breathing. She made a healthcare assistant aware of this who then pressed Michelle’s emergency buzzer.

Staff started performing CPR and a call for a specialist resuscitation team was requested via the hospital switchboard.

An internal investigation by the Hospital Trust found doctors had to call the switchboard for the exact location because the operator had not taken down the ward details.

At around 1.47am a doctor tried to open Michelle’s wound with clippers. However, these were inappropriate because the wound had been glued and not stapled.   

Around two minutes later the doctor realised they needed a scalpel to open the wound and a second crash team call was made at 1.49am. Within a minute a scalpel was found and blood clots removed and an airway established. 

Michelle was taken to theatre for an emergency tracheostomy. Following tests it was established she had suffered a serious brain injury caused by a lack of oxygen.

Michelle had to be artificially fed through a tube.  At her Best Interest Meeting on 23 October, 2017, doctors and Michelle’s family and friends all agreed that Michelle herself would not have wanted her artificial feeding to continue.

On 13 February a High Court Judge agreed that it was not in Michelle’s best interests to have continued nutrition and hydration and this was withdrawn. She died just over two weeks later.

Oxford University Hospitals NHS Foundation Trust carried out an internal investigation. It found the ‘root cause’ of Michelle’s brain injury was that “arrangements to appreciate the risk of, and immediately treat, a rare but known life threatening emergency…were not in place” on the ward where she was taken.

As well as ward staff lacking training or instruction on what to do in the event of an emergency post-operative bleed, the Trust also found that a ‘thyroid emergency box’ containing a scalpel – which might have helped staff realise it was needed to open Michelle’s wound – was not available.

The report made a number of recommendations including staff on wards that take thyroidectomy patients undergo training to identify and manage complications, including post-operative bleeds. Staff will also receive a post-operative fact sheet guiding them through what to do in an emergency and switchboard operators are to receive updated training.

Mark added: “Michelle was a uniquely enchanting person, whose magic touched everyone she met. Friends and colleagues – some of whom I had never met – would repeatedly tell me how she had influenced and helped them, and they now wanted to visit and support her during her nightmare post-operative stay at hospital.

“Those seven months were devastating for everyone that saw her: I fervently hope that Michelle herself was never aware of her dreadful situation.

“Whilst it was an incredibly honest and brave decision by her family that Michelle would not have wanted to continue to live in that state, discussing whether someone would have wanted to die is not something I would want any other family to have to go through. I would urge others to consider writing your own Advance Directive.

“Her family will always be angry at what happened to Michelle before and following her original surgery. The principal reason Michelle had to stay in hospital following surgery was due to risk of bleeding. Yet none of the staff caring for her had any training or information on what do if there was a bleed. Nor were low-cost prevention measures such as an emergency box or advice sheet provided.

“It is vital that staff across all sectors of the NHS do not forget the potential risks patients can face simply because such accidents may rarely happen.

“Hospital staff face incredible pressures and deserve the equipment, training and support needed to do their job. If they had it is difficult not to think that Michelle would have received emergency care as soon as her airway was compromised. This would have resulted in her being able to breathe much sooner, she would have avoided her brain injury and ultimately she would still be with us today.”

Yvette Small, Michelle’s sister added: “Michelle was vivacious, happy, hard-working and bubbly character who instantly made you feel welcome.

“She was loved by her family and friends. She was the life and soul that lit up any room with her infectious laughter and smile. You heard her before you saw her.

“These past 18 months have been incredibly hard for the family. It breaks my heart to know that we will never see her, hold her and talk to her ever again.

“When Michelle ‘woke up’ after her emergency surgery I believe she knew that she couldn't communicate or function the way she used to. Sitting by her bedside holding her, hushing her like a frightened child is all we could do.

“My loving darling Michelle wasn't the same person anymore. She had no quality of life.

“This tragedy, that we feel should have been avoided, robbed us of a daughter, sister, aunt, wife and friend. To say we are heart-broken is an understatement.”