Coroner Heidi Connor has called for a review of how private hospitals use and interpret early warning systems which indicate a deterioration in a patient’s condition, after the death of a patient at Berkshire Independent Hospital in 2017.
Simon Healey, aged 60, died from multi-organ failure after contracting sepsis, just nine days after undergoing surgery for bowel cancer. Mr Healey contracted an infection as a result of a bowel leak following the surgery.
His condition began to deteriorate three days after the surgery, but no action was taken at that point to find out why. It was not until six days after the surgery that Mr Healey was diagnosed with a leaking bowel and sepsis which led to his death, despite efforts to treat his condition.
Opportunities for action missed at an inquest into Mr Healey’s death, Coroner Heidi Connor concluded that: “Opportunities for earlier detection of anastomotic leak and subsequent sepsis were missed. If this had been detected at any point up to August 6, 2017 it is likely that he would have survived.”
Mr Healey’s wife, Alison, said that she had raised concerns about her husband’s condition following the surgery, but that she “felt helpless and ignored”. She said: “When I brought up concerns that he was not recovering from his surgery, or that he was deteriorating, I felt like I was being fobbed off with reassurances that different people recovered at different rates. Had sepsis been mentioned earlier, I would have fought to make sure that Simon was transferred sooner; instead I placed my trust in the medical staff trained to care for Simon.”
Review of the ‘National Early Warning Score’ system
The National Early Warning Score (NEWS) is a tool developed by the Royal College of Physicians to assist with the detection of, and response to, a deterioration in the condition of patients. The system has been endorsed by NHS England and NHS Improvement for use in acute and ambulance settings and has been implemented widely across ambulance and acute trusts nationally. In serious cases, the national policy requires a team with critical care expertise to respond to a clinical deterioration.
However, in the Coroner’s report, Ms Connor expressed her concern that private hospitals were too reliant on off-site consultants to review patients in an emergency. She said: “I believe that the NEWS policies in place at private hospitals should be reviewed. This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell.”
In addition, Ms Connor expressed concern that private hospitals were carrying out surgeries in the absence of specialist nurses and critical care facilities sufficient to deal with the complications that may arise.
Fahmidah Ali, solicitor with Medical Accident Group said: “This is a very sad case, particularly since Mr Healey’s death could have been prevented if adequate procedures had been in place. It is deeply concerning that this hospital was so ill-equipped to properly implement the NEWS system and deal with serious complications.”
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