An inquest at Suffolk Coroner’s Court in Ipswich conducted by Mrs Catherine Wood has heard evidence in respect of care and service delivery issues whilst investigating the tragic hospital death of a 73-year-old man who had been admitted for treatment of a fractured hip.
The patient Barry Jefferson had worked for many years alongside his wife Sarah at their Post Office Stores business in Thurston, near Bury St Edmunds. They were close to finalising plans to sell up and spend more time with family, including their young grandchildren.
On 17 August 2020, Barry tripped at home and fractured his right hip, which had previously been replaced. After relatively straightforward surgery was performed on the periprosthetic fracture at West Suffolk Hospital on 20 August, he was slowly recovering in the orthopaedic ward and appeared to be doing well.
Bloating and swollen abdomen
Placed in a side room due to a positive MRSA test, by 27 August Barry was unwell with nausea and vomiting. During August Bank Holiday weekend, he told nurses he felt bloated and had a swollen abdomen. The nursing team consulted doctors on call, who prescribed medication for bloating.
Over the course of the bank holiday weekend, Barry became increasingly unwell and despite repeated escalation from the nursing staff, he was only reviewed by very junior doctors, going five days without review or input from senior clinicians. In addition, following clinical reviews, documentation was often poor or missing, and there appeared to be a lack of understanding of the changing clinical picture.
On Tuesday 1 September, a review by the advanced nurse practitioner pointed to a possible infection, source unknown. At this stage Barry had not been reviewed by a senior clinician since before the weekend and there had been no proper investigations into his abdominal distension. Antibiotics and fluid were administered intravenously but Barry became more unwell overnight and began vomiting.
A consultant conducted a further review in the afternoon and, suspecting a possible bowel obstruction, ordered nil by mouth and an abdominal X-ray. The X-ray that afternoon showed distended loops of small bowel consistent with an obstruction.
Following the X-ray and referral to the surgical team, Barry suffered further deterioration and an emergency call was activated. Probable irreversible organ failure was suspected when he did not respond to resuscitation treatment by the emergency team. Sadly, he died a short time later.
Care and service delivery issues
Following Barry Jefferson’s death on 2 September, ultimately due to cardiac arrest, a Serious Incident Report was completed by West Suffolk NHS Foundation Trust. This identified a number of care and service delivery issues and pointed to several root causes.
“The report highlighted a series of delays in recognising deterioration in Barry’s condition during that fateful bank holiday weekend and tardiness in seeking senior reviews and investigations,” explains specialist solicitor Craig Knightley of Tees Law, acting for widowed Sarah Jefferson.
“A more timely response earlier in the weekend might have led to a different outcome in this case. Establishing why things went so badly awry has not been helped by a repeated lack of documentation by the junior doctors who reviewed Barry, it being recorded during the inquest that the documentation fell far below what would have been expected from a junior doctor.
“Review by a senior clinician should have occurred sooner, with particular emphasis over the bank holiday weekend. This could have led to an urgent surgical review, with investigations such as the abdominal X-ray and nasogastric tube insertion occurring sooner.
The inquest heard from a senior member of the Hospital Trust who confirmed that the Trust had found that a lack of appropriate senior review over the Bank Holiday weekend led to a failure to recognise Barry’s deterioration, late investigation and late treatment.
There was further found to be an inconsistent approach to handover of patients out of hours, leading to poor communication between teams, failure to review/monitor for deterioration and delay in escalation of a sick patient. The lack of a Sick List meant that patients who required close monitoring were not routinely monitored or reviewed.
Following the Trust’s internal review, a number of measures have now been put in place including a revised handover within surgical division, use of a Sick List during handovers for general surgery and orthopaedic teams, development of a Standard Operating Procedure for a revised handover process, as well as shared learning in respect of escalation of patients and the importance of documentation to junior doctors.
A second ortho-geriatrician to the surgical division is also being recruited to work towards the Trust’s goal of every orthopaedic patient receiving a review by a senior doctor Monday to Friday with senior surgical review out of hours as needed.
“Sarah Jefferson is grateful to the Coroner for the thorough investigation into Barry’s death. Hopefully, following the Hospital Trust’s findings and the measures that have been implemented since Barry’s death, the incidence of failures to escalate the response to clearly deteriorating patients will have been greatly reduced.”
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