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The Acting Senior Coroner for East London, Mr Graeme Irvine, has held that the death of a patient following elective surgery was an unlawful killing, due to the failures of the consultant anaesthetist. Ellen Robertson, led by Ali Naseem Bajwa QC and instructed by Faradays Solicitors, represented the family of Mrs S, a 78-year-old woman, in the inquest into her death following an elective revision total hip replacement operation in September 2018 at the Gateway Centre, a Barts Health NHS Trust surgical centre.
Mrs S was assessed as a suitable candidate to undergo the surgery at the Gateway Centre despite its lack of any critical care facilities and her significant pre-existing morbidities. The Trust conceded that Mrs S was not a suitable candidate for the Gateway Centre. Due to failures in the pre-operative assessment, Mrs S was not given accurate information about the risk of death. During the operation, the surgical team breached the femoral cortex and the operation was extended to allow for the placement of a metal plate. The lead Consultant Surgeon left prior to the conclusion of the operation. Mrs S’s blood pressure was dangerously low for lengthy periods, which led to organ failure. Despite the efforts of an intensive care team, Mrs S passed away some hours after the operation ended.
The Acting Senior Coroner found that the Consultant Anaesthetist had failed to utilise cardiac output or other monitoring that would have given greater diagnostic information about Mrs S’s condition, allowed Mrs S’s blood pressure to remain at dangerously low levels for extended periods of time, and failed to appreciate that Mrs S required urgent fluid resuscitation. The Acting Senior Coroner also identified numerous failures of the anaesthetist in the post-operative care, including his decision to leave the Gateway Centre for the day when Mrs S was in a critically unwell condition.
In particular, the Acting Senior Coroner criticised the agreement of the Consultant Anaesthetist to extend surgery despite Mrs S’s critically unwell state, and determined that to be an act that amounted to such a truly and exceptionally bad breach of duty, that the test for gross negligence manslaughter was met. He therefore entered a conclusion of unlawful killing.
In addition to the failures by the Consultant Anaesthetist, the Acting Senior Coroner found that there were a number of other failures in the Trust’s care, including failures to adequately assess Mrs S’s condition in pre-operative checks or to appreciate her serious comorbidities, a failure to use any appropriate pre-operative assessment algorithm, a failure to obtain adequately informed consent, a failure to appreciate that the Gateway Centre was not an appropriate location for the operation and a number of failures in the post-operative care provided to Mrs S.
The Acting Senior Coroner formed the view that the circumstances amounted to a failure in basic medical care by the Trust, which were gross failures and had a clear connection with Mrs S’s death. He formed the view that the failures amounted to neglect, but given the findings in relation to the anaesthetist, the appropriate conclusion was one of unlawful killing.
The Acting Senior Coroner has issued a Report to Prevent Future Deaths in relation to the failure of the Trust to utilise any formal risk assessment tool when assessing the pre-operative risk to Mrs S, and the ongoing failure of the Trust to require the use of such a tool. The Report also addressed the poor communication between the orthopaedic surgical team and the anaesthetist, finding that no targeted questions had been asked about Mrs S’s condition and that a different outcome may have arisen had such questions been asked. The Report also found that the lead consultant surgeon’s decision to leave the surgery early had lengthened the procedure, yet no system was in place to assess whether that decision was appropriate.
In addition to Barts Health NHS Trust, the Report has been sent to the Department for Health and Social Care, the Royal College of Surgeons and the Royal College of Anaesthetists.