Hospital errors led to woman’s death after weight-loss surgery, coroner says

Faults at a hospital contributed to the death of a 55-year-old woman who suffered abdominal sepsis after weight-loss surgery during a junior doctors’ strike, a coroner has said.

Susan Evans returned to Queen Alexandra Hospital in Portsmouth, Hampshire, two days after surgery with stomach pain elective gastric bypass surgery.

She was sent home without being seen by a member of the specialist bariatric team or a senior doctor, even though hospital policy says this should happen, and became seriously unwell.

Evans returned to the hospital and underwent two more surgeries, but died a month after the original procedure.

In a report on the prevention of future deathsCoroner Sally Olsen said no written or informal policy had been followed and failures had “contributed more than minimally” to Evans’ death.

She said Evans had surgery on July 11, 2023 gastric bypass surgery. The operation went according to plan and appropriate measures were taken to avoid the possibility of anastomotic leak, a rare but recognized complication.

Evans initially recovered well but developed abdominal pain in the early hours of July 13, 2023, which was likely caused by an anastomotic leak.

The coroner emphasized that it was the first day of a strike by local doctorspreviously called junior doctors. She said: “What had nothing to do with this was that the hospital only had the equivalent of one full-time specialist bariatric nurse, who was off duty.

“Contrary to Queen Alexandra Hospital’s written policy for gastric bypass patients, on July 13, 2023, Ms Evans was not seen by a member of the specialist bariatric team and was not seen by a senior doctor after reporting pain to possibility of exclusion. anastomotic leak. The hospital’s night care team, which administered pain relief, was unaware of this latest requirement.

“In addition, Ms Evans was not seen by a member of the bariatric team or a doctor prior to her discharge from hospital on the morning of July 13, 2023. Ms Evans was still in some degree of pain when she left hospital.

“She was readmitted to hospital on July 15, 2023. At the time she was extremely unwell with abdominal sepsis due to an anastomotic leak. She underwent repair surgery on July 15, 2023 and required further surgery on July 25, 2023.”

Her condition deteriorated and she died at Queen Alexandra Hospital on August 12, 2023. The coroner said: “It is likely that had she been seen by a member of the bariatric team on July 13, 2023, she would have been retained in hospital. hospital and would have undergone surgery earlier. The identified failures contributed more than minimally to her death.

“Neither the written nor informal policy was followed in the case of Ms. Evans.”

The University of Portsmouth Hospitals NHS Trust has until February 7 to respond to the coroner, who said it would have to implement any measures it has taken or proposed, and add a timetable for action – or explain why no action has been proposed.