Patient died after error and delays in hectic hospital
Posted on December 12, 2006
A widow says she has lost her faith in the NHS after a catalogue of delays resulted in the sudden death of her husband.
Brock Shaw, a tireless worker for the Eaton Bray and Edlesborough Carnival, had gone into Stoke Mandeville Hospital for a simple routine operation to remove a small growth from his colon.
But a few hours after the surgery the Australian-born IT consultant, from Leighton Road, Soulbury, began suffering the first effects of septicaemia caused when surgeon. Zachariah Michael. accidentally burnt a hole in his colon with the endoscope.
An inquest in Amersham heard on Tuesday that Dr Michael immediately reported his fears to specialist surgeon VK Gahlot, but it took the surgeon five hours to visit Mr Shaw because he was busy running a clinic and responding to other emergencies.
In the mean time Mr Gahlot ordered that the patient, who was in excruciating agony, be given "conservative treatment" of antibiotics, painkillers and fluids rather than be considered for emergency surgery in the hope that the hole, a little smaller than a penny, would repair itself.
His shocked widow, Rebecca, told coroner Richard Hullet, that it took three requests and more than an hour for morphine to be administered while her husband curled into a foetal position to escape the pain. He began vomiting and sweating as his blood pressure and heart rate went through the roof.
As Mr Shaw's condition deteriorated it was left to the persistence of an unqualified health care assistant to raise the alarm. When it was finally agreed that 61-year-old Mr Shaw needed an emergency operation it was found that all the theatres were full.
He was finally operated on 12 hours after being diagnosed with a suspected perforated bowel by which time the father-of-three had developed peritonitis and he died the following day of multiple organ failure.
Expert witness Professor Neil Mortensen told the inquest that he would never have made a patient wait for emergency treatment and that Mr Shaw should have been pushed to the head of the queue for theatre.
He said: "It's not clear why there was a five-hour delay before Mr Gahlot reviewed Mr Shaw. Certainly earlier intervention would have prevented septicaemia. I have always found that the earlier the intervention the better the outcome.
"If I had strongly suspected a perforation I would have done all I could to find an available theatre.
"I feel there was an unacceptable delay between the suspected perforation being identified and the operation."
Mrs Shaw told the coroner that her husband had been advised to have regular tests after his father had died of bowel cancer.
"He'd had about four tests over ten years and they all went smoothly. He'd have the test, a cup of tea and we'd go home.
"This time around they found a small polyp and decided to remove it. We had expected to go home afterwards and had planned to go out for lunch."
Mr Michael said the operation to snare and retrieve the polyp wasn't complicated and was "a routine procedure." He said that the growth would develop into cancer of the colon if left.
"The procedure carries a well-recognised risk of perforation. I examined him after the procedure and a perforation was the only explanation for his symptoms.
"I have not personally experienced a perforation before but the majority of perforations respond to treatment and don't need surgery. The majority seal by themselves."
Mr Gahlot said that the afternoon Mr Shaw was admitted he had been the surgeon on call to outpatients, was running a breast clinic and was answerable to emergencies from the A & E department.
"It was pretty hectic. I was informed Mr Michael had admitted the patient during the afternoon for observation and I saw him at about 7.15pm. I reviewed him again about three hours later.
"I consulted with Mr Farouk and he advised surgery. I operated on Mr Shaw, finishing at about 4am.
"There had been no deliberate delay. As soon as I got some free time I saw the patient. Casualty is very hectic and they are always a priority. They kept calling to consult.
"I was so busy I didn't have the time to see Mr Shaw earlier but I was being informed constantly by my house officer, who is a very good doctor, about what was going on with the patient."
Consultant surgeon Marwan Farouk said he was told at about 10pm that Mr Shaw's symptoms had worsened.
"I was very concerned about him but there was no theatre available at that time."
Coroner Mr Hullet asked the doctor "Was the whole system clogging up?"
"It was clogging up which was unfortunate," he said. "I asked for him to queuejump to the head of the list. He was more important than fixing a fracture.
"After surgery I don't know why he didn't recover. Once you remove the sepsis the body usually recovers. He should have recovered pretty quickly.
"I would have expected him to survive the operation but he didn't survive because of the overwhelming sepsis that then affected his other organs."
In recording a narrative verdict Mr Hullet said: "On June 20, 2005, at about 10.30am, Mr Shaw underwent a pre-planned colonoscopy and polypectomy as a day patient at Stoke Mandeville Hospital.
"The procedure resulted in a perforation of the colon and diagnosis of a high possibility of such a perforation was made at 1pm.
"A surgical repair of the colon took place between 1.30am and 3.30am on June 21 but Mr Shaw failed to make a recovery and died at 9.30am on June 22."
After the inquest Mrs Shaw, a graphic designer, said the couple, who were married 21 years, had given up private health insurance when they moved from America to Britain in 1984.
"Brock had tremendous faith in the NHS. He said that if we were going to live here we had to take the good with the bad and part of that was to believe in the NHS.
"You believe what doctors tell you. We trusted the NHS and they let us down. I owe it to my husband to ensure as far as I can that this does not happen to anyone else.
"Brock was a wonderful man and I miss him so much. A brilliant mathematician, an artist, he composed music. He even wrote a piece of music for our daughter, Becki's wedding.
"Everyone in Eaton Bray and Edlesborough knew him because of his work with the carnival but we were also regular churchgoers at St Mary's and lived in Eaton Bray for many years."
Source: Anne Cox, Leighton Buzzard Observer, 12 December 2006
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