Mr Francis Hodge · Prevention of Future Deaths report

On 23 November 2019 this jurisdiction commenced an investigation into the death of Mr Francis Hodge. The investigation concluded at the end of the inquest on 30 August 2019. The conclusion of the inquest was that Mr Hodge died as a result of the unintended consequences of medical treatment.

Mr Hodge died on 16 November 2018 at University Hospital Lewisham due to a perforated colon. Seven days prior Mr Hodge had undergone an elective laparoscopic repair of multiple incisional hernias. These had developed at the site of previous abdominal surgeries. Additionally Mr Hodge suffered with pre-existing diverticular disease. The surgery had proceeded without complication. The subsequent development of the perforation was within an area away from the operation site and was very unexpected. It is likely it represented the coincidence of a bowel rendered vulnerable by pre-existing pathology returning to normal bowel function following surgery.

(1) At inquest I was told that on discharge Mr Hodge was given inadequate discharge advice. He was advised to rest as much as possible and that if he were to remain in severe pain in a week's time he should return.

(2) The consultant who undertook the surgery explained that such discharge advice was not what should have been provided to a patient following this surgery. The patient should have been told to be concerned about and to look out for: breathlessness, pus or redness, and / or pain which would not settle.

(3) Mr Hodge was suffering breathless the night before his collapse and pain which would not settle. He however, did not want to seek medical advice. I am told, because he was following what he had been told to do on discharge.

(4) I was also told that no patient information leaflet existed for this type of surgery as it was not a common type of procedure.