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Investigation and inquest
On 29th January 2013 I commenced an investigation into the death of James Hadfield Withers (dob 16/8/26). The investigation concluded at the end of the inquest on 19th September 2013.
The conclusion of the inquest was “In October 2012 Mr Withers was diagnosed as suffering a recurrent of carcinoma in the bowel. He was admitted to hospital as a resection of the affected area on the 11th December 2012: Immediately post operatively he was treated on the ITU and made very good progress. He was then transferred to the surgical ward and his condition generally deteriorated thereafter: During his time on this ward and after his return to the ITU there were a number of occasions of poor communication with the family of the deceased; he was thought to be classified as DNAR when a doctor mistook him for another patient; little or no explanation was given to the family as to his actual DNAR status and/or as to why it was deemed appropriate as to why and when it was decided to take him off ventilation. On the 27th January 2013 he died as a result of his diseased heart, contributed to by the stress of the necessary operation to remove the cancer”
The medical cause of death was 1a Congestive Cardiac failure 1b left ventricular failure 1c valvular heart disease (aortic stenosis) 2. Open extended right hemi-colectomy for invasive colonic adenocarcinoma
Circumstances of the death
The circumstances are apparent from the conclusion as outlined above
The published report provides this section by reference to another part of the report.
Coroner’s concerns
1. There was a delay of five days between the Cardiologist being requested to see the patient and actually attending the patient.
2. Various of the medical/nursing notes appear to have gone missing
3. The patient’s DNAR status was fixed without any reference to/discussion with his family. Whilst it is appreciated that this decision is for the doctor alone, good practice would require that the family be kept up to date with all such decisions
4. One of the doctors admitted that he had assumed an incorrect DNAR status based on the fact that he had two separate pieces of paper in his pocket and had looked at the wrong one.
5. There was generally poor communication between nursing and medical staff (inter se) and between medical/nursing staff and the family of the patient.