Betty SMITH · Prevention of Future Deaths report

On 1st November 2012 I commenced an investigation into the death of Betty SMITH. The investigation concluded at the end of the inquest on 2nd April and 10th September 2014. The conclusion of the inquest was that Betty SMITH died as the result of the unintended consequence of necessary surgical treatment.

Betty SMITH required surgery for a large intrathoracic hiatus hernia. She had significant comorbidities. She was referred to the Anaesthetic Department who advised that surgery should proceed after six months of warfarin for treatment of a pulmonary embolus, from review of the medical records only and not after a consultation with her.

There was no barium swallow or endoscopy which the expert opinion considered would have demonstrated evidence of volvulus or obstruction.

On 22nd October 2012 she was admitted for laparoscopic Nissen Fundoplication with mesh which was uneventful. She was due to go to the High Dependency Unit post-operatively but remained in recovery for several hours before going to the ward with just a drain and no invasive support as there was no HDU bed available.

She deteriorated the following day and began a heparin infusion for a pulmonary embolism. She was admitted to ITU on 24th October 2012 and died the following day.

Cause of death was:-

1a) Intraabdominal and intrathoracic haemorrhage
1b) Repair of hiatus hernia

• To return Betty SMITH to a ward post-operatively and not secure an High Dependency Unit bed before surgery commenced falls well below accepted care. The expert opinion was concerned that such a high risk patient should have been referred to a Tertiary Centre for a second opinion and probably management.

• The pre-assessment service offered by the Anaesthetic Department is far from adequate. To review such a high risk patient with significant comorbidity from the medical records is not in the patient’s interest. Time should be afforded to the anaesthetists to review the patient at an out-patient clinic pre-operatively to assess the risks and discuss them.

• Two ITU beds have been closed three months ago due to nursing shortages leaving William Harvey Hospital with just nine ITU beds. This is 4.5 beds per 100,000 population compared to the national average of 6.4 ITU beds. This is presenting the ITU Intensivists with significant difficulties and compromises the care of those patients requiring intensive therapy in a busy district general hospital.