74-Year-Old Man Died At Hinchingbrooke Hospital In May 2017

The widow of a father-of-four from Fenstanton, who died while a patient at a Cambridgeshire hospital, has revealed her hope that the lessons will be learned after an inquest into his death.

Retired electrician Keith Woodroff died aged 74 at Hinchingbrooke Hospital on 5th May last year after being admitted to the hospital on 24th April with pneumonia. 

Keith received treatment for over a week in hospital and underwent a tracheostomy in an attempt to wean him off a ventilator on Thursday 4th May. Following the procedure Keith rapidly deteriorated and tragically passed away in the early hours the next day. An internal hospital investigation found that part of his treatment was not appropriate for his condition at the time.

A three-day inquest into Keith’s death was held at Huntingdon Coroners’ Court between 9th and 11th October 2018, where Assistant Coroner Rosamund Rhodes-Kemp heard evidence from Keith’s family, two expert clinicians, and staff at the Hospital Trust including Dr Muhammad Asif, the consultant responsible for his care. 

The evidence addressed the pattern of decision making leading to the procedure and the complications arising from it. In her conclusion, Mrs Rhodes-Kemp acknowledged that there had been errors in the way in which Keith’s care was managed, highlighting in particular that the planning and documenting of Keith’s treatment had been poor.

After his death, Keith’s family instructed specialist lawyers at Irwin Mitchell’s Cambridge office to investigate the care he received and to support her through the inquest.

Gurpreet Lalli, the solicitor and medical negligence expert at Irwin Mitchell representing the family said: 

Expert Opinion

“This is a truly devastating incident in which a family has lost a much-loved husband and father. The inquest has provided vital information regarding the care that Keith received and we are concerned by a number of issues which have been raised.

“Expert evidence has revealed a series of failings in Keith’s care prior to his death, from the timing of the procedure to the failure to seek help once complications became apparent.

“We hope that lessons are learnt and the Trust implements changes in order to avoid the loss that Keith’s family have suffered.” Gurpreet Lalli - Senior Associate Solicitor

The inquest heard that prior to his illness, Keith was a fit and active man who regularly would help his friends and his neighbours in and around the community.

Expert critical care consultants, Dr Stuart Booth, who contributed to the internal hospital investigation, and Dr Ken Power from whom the coroner sought expert opinion prior to the inquest attended and gave oral evidence. 

The inquest heard that Mr Woodroff was critically unwell during the procedure. Both experts agreed that a tracheostomy was premature and that Dr Asif should have given Keith’s condition a chance to improve before proceeding, particularly as several colleagues had questioned his intentions hours earlier. 

Dr Power described Dr Asif’s decision as “an error of judgment” and Dr Booth said there was “zero benefit” of performing a tracheostomy at that time.

The procedure was attempted several times unsuccessfully. Both experts concluded that it would have been appropriate to seek help or abandon the procedure when complication arose. Dr Asif was unaware that Keith’s trachea had been damaged during the procedure, and that he was bleeding internally

Additionally, it was found that Keith remained on blood thinning medication throughout the procedure and for two hours afterward which Dr Booth stated “certainly exacerbated” the bleed which ultimately caused Keith’s death.

Several hours later doctors realised that Keith’s trachea had been damaged as his condition rapidly deteriorated. However, no attempt was made to call for assistance or to repair the damage caused and Keith suffered a cardiac arrest and died in the early hours of Friday morning. 

Experts were critical of Dr Asif’s failure to seek urgent advice from a specialist surgeon when the damage became clear.

Ann, 72, who has four adult-children with Keith, said: “Going through the inquest process has been incredibly difficult, particularly learning of the flaws in Keith’s treatment.

"While it is obviously too late for Keith, we are now hopeful that we can ensure lessons are learned from what happened to him so that it doesn’t happen to anyone else.”

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