Derek Edward Hare · Prevention of Future Deaths report

On 19th August 2015 I commenced an investigation into the death of Derek Edward Hare dob 15th August 1937. The investigation concluded on the 13th January 2016 and the conclusion was one of Misadventure. The medical cause of death was a Multi organ failure 1b Chest and abdominal sepsis 1c Colonic Anastomotic Failure treated by surgery on 19.6.15: Embolization on 17.4.15 after Colectomy for diverticulitis on 14.1.15 11 Ischaemic Heart Disease.

Mr Hare was subject to severe abdominal pains and he was admitted to the hospital in January 2015 and was operated on for a colectomy. Thereafter he asked a numerous occasions to see the surgeons again as he was still in pain and was passing blood per rectum, but was refused/denied the chance to see the doctor. Eventually he was looked at and it was determined that one of his major blood vessels needed embolization. This embolization was done at Wythenshawe Hospital and on his return to Tameside he underwent a colonscopy to examine the bowel. The embolization had compromised the blood supply to that part of the bowel where the anastomosis had been formed, and when the bowel was inflated for the colonoscopy, it caused the anastomosis to fail leading to a loss of bowel content and the development of sepsis in the abdomen and the chest.

1. It would appear that throughout his various admissions to the hospital, two completely separate sets of “notes” were open and being used. Thus when the doctor tried to refer to the notes in court he could not do so and had to seek a short adjournment to find the relevant entry. If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient.

2. The deceased incessantly asked for appointments at the hospital because he knew that his abdomen was “not right”, yet he was constantly refused/denied such an appointment. This meant that it is possible that the problem which he had was diagnosed much later than might have been the case, and the outcome might have been different.

3. On the 5th May 2015 he was admitted via emergency ambulance to TGH with abdominal pains. On the 6th May it was determined that he did not need an emergency colonoscopy and the “urgency was not there”. He was sent home. He attended on the 19th June and had to undergo a laparotomy when the problem of the broken anastomosis was discovered and he died on the twelfth August. It was agreed by one of the consultant surgeons giving evidence to me that it would have benefited his care to have kept him in hospital on the 6th May.