Lita SERKES · Prevention of Future Deaths report

On 27 July 2016 I commenced an investigation into the death of Lita Serkes, aged 80 years. The investigation concluded at the end of the inquest earlier today.

I made a determination at inquest that Lita Serkes died from a complication of a hysterectomy undertaken for endometrial cancer, being a devastating bleed, the gravity of which was not immediately recognised.

I recorded a medical cause of death of:
1a intra abdominal haemorrhage
1b total abdominal hysterectomy and bilateral salpingo-oophorectomy
for endometrial adenocarcinoma, on 22.07.16
2 diabetes mellitus, hypertension, right cerebral infarct

The surgery performed at Whipps Cross Hospital on Friday, 22 July 2016, was unremarkable. However, the following morning, Mrs Serkes suffered a stroke and was transferred to the Royal London Hospital. By that evening she was extremely unwell, and she died on Sunday, 24 July.

1. The Whipps Cross medical notes record normal observations, most specifically that Mrs Serkes was “alert” at 9.50am on Saturday, 23 July 2016. However, by that time, her son had been at her bedside for nearly an hour and had himself realised that Mrs Serkes had suffered a stroke. He saw no nurse conducting any observations at this time.

Some five months on, no member of staff has yet addressed this discrepancy with the nurse who recorded the observations.

2. When Mrs Serkes’ treating consultant gynaecological surgeon attended her at 10.30am on Saturday, 23 July, he formed the impression that he was the first person to diagnose the stroke.

In fact, her son and another doctor had already discussed the stroke, and her son was under the impression that they were simply waiting for an ambulance to transfer to the Royal London Hospital. (He was already making arrangements to drive his father there.) None of this is recorded in the medical notes.

3. The decision was made by, at the latest 10.30am, but quite possibly an hour before then, to transfer Mrs Serkes to the Royal London Hospital for specialist care, but transfer was not effected until 2.07pm.

Stroke is an emergency.

4. Patient controlled administration of pain relief was arranged for Mrs Serkes, but she remained in pain. It was quite some time before it was recognised that the device was not connected and so was not delivering any analgesia.

5. Mrs Serkes’ surgeon went to the Royal London Hospital to see her at 10.30pm on Saturday, 23 July. He described in court palpating her abdomen and there being no rigidity, guarding, or further distension.

However, he made no record in the medical notes of his attendance and examination.

6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre.

However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active.

When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day.

After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital.

He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated.

He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that.

7. The surgeon suggested that perhaps bloods should be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this.