Hospital Trust Admits 12-Hour Urgent Care Delay Following Complications After Cardiac Surgery

A family are urging a Hospital Trust, where police are investigating dozens of deaths, to improve patient safety after a dad’s “needless” death following a 12-hour delay in urgent care.

Around eight hours after aortic valve replacement surgery at Royal Sussex County Hospital in Brighton, Ralph Sims suffered a sudden drop in blood pressure and developed an irregular heart rhythm at around 10.30pm on 5 April, 2019. This was the result of a blood clot which was causing reduced blood flow to the heart. 

Brighton hospital staff failed to recognise significance of patient's condition

However, hospital staff failed to “recognise the significance of the fall in blood pressure,” an internal NHS investigation report seen by medical negligence lawyers at Irwin Mitchell found. 

Whilst staff attempted to treat Ralph’s deteriorating blood pressure, University Hospitals Sussex NHS Foundation Trust accepted that the father-of-three should have been returned to theatre for an angiogram in order to identify the cause of his post-operative deterioration. Instead, medics decided that he should be observed overnight. 

Furthermore, the case was not referred to an on-call cardiology consultant based 14 miles away in Worthing, contrary to the unit’s policy. 

Ralph didn't undergo urgent angiogram for more than 12 hours

It was only during normal working hours the following morning – 6 April, 2019 – that an urgent angiogram to assess Ralph’s blood flow was arranged. However, due to another emergency case at the hospital, the urgent angiogram was not carried out until just before midday, the Trust’s incident investigation said. This was more than 12 hours after the initial drop in blood pressure. And it was too late for Ralph.

When the angiogram, which started at around 11.45am was finally carried out, it showed reduced blood flow to the heart, caused by a clot. Ralph, of Burgess Hill, then had a stent fitted. But because of the more than 12-hour delay in surgical intervention, Ralph had already suffered irreversible – and otherwise avoidable – heart muscle damage. 

The retired project manager and keen marathon runner spent two weeks in intensive care before being transferred to a specialist unit for a heart transplant. However, he was too poorly to be considered for a transplant and died aged 65, five weeks later on 25 May. 

Medical negligence lawyers asked to investigate Ralph's care

Following Ralph’s death, his family instructed expert medical negligence lawyers at Irwin Mitchell to investigate his care under University Hospitals Sussex NHS Foundation Trust. 

His loved ones have now joined their legal team in calling for lessons to be learned. It comes after Irwin Mitchell secured an undisclosed settlement from the Hospital Trust which admitted liability for Ralph’s death. 

After initially denying liability for many months, Irwin Mitchell issued High Court legal proceedings against the Trust, following which, it admitted that Ralph should have been returned to theatre and undergone an angiogram within 90 minutes of his post-operative deterioration – and no later than midnight that night. Had this taken place, the Trust further accepted that a stent would have been fitted and Ralph would not have died on 25 May 2019.

The Trust has apologised to the family for the failings in care. 

Thomas Riis-Bristow, is a specialist medical negligence lawyer at Irwin Mitchell who represented the family. 

Expert Opinion

“Ralph’s loved ones continue to be deeply traumatised by his death.

“Worrying failings have been admitted by the Trust. Every minute counts in cardiac surgery and, the longer reduced blood flow is left untreated, the more damage is caused to the cardiac muscle over time. Tragically, in Ralph’s case, had he received adequate care, his death would have been entirely avoidable. This is the impossible reality that his family must now face.

“While nothing can ever fully rectify the family’s and Ralph’s suffering, we’re pleased that, through the legal process, we’ve been able to provide Ralph’s loved ones with the answers they deserve. It’s now vital that the Hospital Trust learns lessons from the failings Ralph suffered to improve patient safety for others. Ralph’s family don’t want others to suffer another needless tragedy.” Thomas Riis-Bristow

University Hospitals Sussex NHS Foundation Trust's internal report findings

The Hospital Trust’s internal incident investigation report found seven key contributory factors. These included: 

• There was a delay in taking Ralph to the cath lab – a unit where an angiogram takes place.

• That delay was as a result of a failure to recognise the significance of the fall in his blood pressure.

• The fact that the on-call cardiology consultant was based in Worthing and was ostensibly covering only emergency surgery may have contributed to the delay in requesting an angiogram.

• The failure to inform the on-call surgeon was “a deviation from the unit policy”.

Ralph's loved ones pay tribute to wonderful family man as they call for improvements in patient safety

Ralph’s family said: “Ralph was a wonderful, husband, and father, who was adored by all of his family. 

“He was a keen runner and used his love of running to help others, taking part in many fundraising events in aid of charity. 

“While heart surgery isn’t something minor, when he went into hospital we never imagined the events that unfolded and he’d never come home. 

“Seeing him in those final weeks was so upsetting. Ralph was a genuinely kind man who didn’t deserve to suffer and die in the way he did. 

“While time has moved on it hasn’t for our family. The hurt and pain we continue to suffer is a strong now as it was when he died. 

“The hardest thing to try and come to terms with is that Ralph’s death should have been avoided. 

“Whilst the Trust has apologised to our family it feels hollow. Ralph’s death was entirely unnecessary, and despite the issues in his care, it took the Trust several years to apologise.

“The best thing the Trust can now do is to ensure guidelines and protocols are followed. Staff didn’t contact the surgeon who had completed the surgery, send Ralph for an angiogram in time and didn’t seek the advice of the on-call consultant, who wasn’t even on site, but was 14 miles away in Worthing. The outcome could have been very different if these things had been done, as they should have. 

“It would be difficult to exaggerate the pain and suffering that Ralph went through. We just hope that by speaking out we can prevent other patients and their families having to suffer an agonising and distressing loss of a loved one in this way.” 

Police investigate more than 100 cases of alleged medical negligence  

Police are now investigating more than 100 alleged cases of medical negligence, known as Operation Bamber, connected to the Hospital Trust, including at Royal Sussex County Hospital in Brighton.

A police investigation was launched in June 2023 after two whistle-blowers made allegations about patient safety connected to the general surgery and neurosurgery departments.

The claims included that University Hospitals Sussex NHS Trust failed to properly investigate deaths, near misses, and learning from mistakes. 

Last November police widened their review to include more recent cases than those previously identified. The concerns are now believed to involve alleged mistakes in the treatment of more than 100 patients from 2015 and 2021, including at least 40 patients who died.

Expert Opinion

“Upholding the highest standards of care should always be the fundamental priority for Hospital Trusts, therefore the ongoing police investigation is very concerning.

“We’re continuing to support families who have contacted us separately from the police investigation to help establish answers to their questions.

“It’s vital that families who may have concerns following this latest development also receive the care and support they may need to get through this difficult time and that the police are also allowed to carry out their investigation unhindered.” Thomas Riis-Bristow

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