David MOSTARI · Prevention of Future Deaths report

On 14 August 2015 I commenced an Investigation into the death of David MOSTARI, aged 70 years. The Investigation concluded at the end of the Inquest on 13 January 2016. The Conclusion of the Inquest was a “Narrative Conclusion” that: “…The deceased was admitted to Bedford Hospital on 8 August 2015 at 11:03 hours. He was seriously unwell and there was a failure to recognise the serious nature of his condition and a failure to take the necessary steps to treat him appropriately. This resulted in a lost opportunity to intervene earlier and he died on 10 August 2015 from peritonitis following a perforated bowel”.

The Deceased was admitted to Bedford Hospital South Wing at 11.03 hours on 8 August 2015 with a history of suggested flare up of his ulcerative colitis. He was managed on a Ward until he deteriorated in the early hours of 10 August 2015. He was then taken to the Critical Care Complex and subsequently into theatre where a laparotomy was performed. A perforated colon with widespread faecal contamination was found, and a partial colectomy performed. On return from theatre he remained moribund but further resuscitation allowed commencement of haemofiltration. Unfortunately he continued to deteriorate and later that evening it was apparent that treatment was futile and hence, with the agreement of the family, withdrawn.

1. Mr. Mostari was admitted to the Hospital on a Saturday and despite the need for an urgent x-ray and ultra sound scan the tests were not in fact carried out until the Monday. There therefore does not appear to be any robust system in place for ensuring that urgent tests and imaging are carried out without delay, particularly when a patient is admitted at the week-end. The deceased needed the tests and follow up treatment as a matter of urgency.