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Investigation and inquest
On 21 February 2025 I commenced an investigation into the death of John Bell. The investigation concluded at the end of the inquest . The conclusion of the inquest was a narrative conclusion that:
The deceased died as a result of recognised complications of a wound infection following appropriate spinal surgery. If the spinal surgeons had been aware of the prior diagnosis of a renal tumour, surgery to treat the renal tumour would have been prioritised and spinal surgery not undertaken at that time. This in turn would have avoided the spinal surgical wound infection and the deceased would not have died when he did.
The Medical Cause of death was:
1a Right upper lobe pneumonia
1b
1c
II Infected spinal surgery wound, ischaemic heart disease, localised left renal carcinoma
Circumstances of the death
Mr Bell died at St John's Hospice Doncaster on 10 February 2025. His death was caused by right upper lobe pneumonia which was contributed to by an infected spinal surgery wound, ischaemic heart disease and localised left renal carcinoma.
On 25 October 2024 he underwent spinal surgery. At the time of that surgery, the spinal surgeon was not aware that Mr Bell had recently been diagnosed with a renal tumour which required curative surgical treatment. If the spinal surgeon had been aware of that diagnosis, spinal surgery would not have been undertaken at this time and surgery on the renal tumour would have been prioritised.
Following the spinal surgery, Mr Bell was started on heparin to treat a renal thrombus which was a complication of the renal tumour. Heparin would not normally have been given following spinal surgery due to the increased risk of bleeding, however, the renal thrombus necessitated the administration of heparin in Mr Bell's case. The heparin in turn caused a wound haematoma which became infected. Despite treatment Mr Bell deteriorated and died on 10 February 2025 as a result of complications of the wound infection.
On the balance of probability, if the spinal surgery had been delayed to treat the renal tumour, Mr Bell would not have developed the haematoma and spinal wound infection and would not have died when he did.
Coroner’s concerns
1. Renal investigations were undertaken following a fast track cancer referral in September 2024. Investigations were undertaken and on 16 October 2024 a renal MDT reviewed CT scans and recommended that Mr Bell be considered for left nephrectomy to treat a renal tumour. Although the MDT note was apparently in the electronic records, the spinal surgeons were not aware of the renal findings at the time of the spinal surgery on 25 October 2024. Had they been aware, spinal surgery would not have been undertaken at this stage with the renal surgery being prioritised. I am concerned that critical clinical information was not available to and/or considered by, the spinal surgeons before the spinal surgery took place.
2. The issue in the previous paragraph came to light shortly after the spinal surgery in October 2024. However, no investigation of the incident was undertaken by the Trust. At the time of the inquest no Datix report had been submitted. The witnesses accepted at inquest that a Datix would have been good practice. I am concerned that some 8 months after the incident no formal investigation had taken place and no consideration of any learning had occurred.
Information checked against the published report and official responses