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Shocking failures at Sussex Orthopaedic Treatment Centre

Coroner raises concerns about SOTC following death of hip replacement woman

Posted on 08 November 2010

On the day Sussex Orthopaedic Treatment Centre(SOTC) placed an advertisement in the local newspaper for Brighton & Hove describing the “high standards of patient care”, “highly trained clinical staff”, and “the latest equipment” it purports to offer, the local Coroner indicated he would be raising with the local Director of Public Health concerns about the operation of SOTC, in line with his duty to do so when there is a risk that other deaths will occur.

The Coroner made these comments in the course of the Inquest into the death of 88 year old Mrs Doris Allen. Mrs Allen went in to SOTC, a treatment centre for NHS patients, run by a private profit making company, Care UK Healthcare Limited, in August 2009 for routine hip surgery. She was categorised as low risk and told the operation would be straightforward. Indeed, the surgery took just 40 minutes to complete.

However, she was not aware that there were basic and serious problems with the SOTC which call in to question its safety. Neither was she told that if anything went wrong she would have to be transferred to Brighton for treatment. As a result of these problems 10 days after undergoing this routine straight forward procedure Mrs Allen died at Royal Sussex County Hospital.

The Consultant Anaesthetist in charge of Mrs Allen’s immediate post-operative care at SOTC discharged her from the recovery area to the ward despite the fact she was demonstrating signs of blood loss. Unbeknownst to the surgeon, one of the arteries in her pelvis had been damaged during the operation, a known risk of hip surgery. Records reveal that at about 4.00pm her blood pressure was abnormal, her abdomen distended and she was pale. She was unable to pass urine and her haemoglobin levels had dropped from 13.2 to 5.8. Despite these signs, described by an independent expert and other medical witnesses at the inquest as being obviously indicative of an internal bleed into her abdomen, the Consultant initially thought she was suffering from a bladder problem. In his evidence given to the inquest he acknowledged that, in fact, a bladder problem was unlikely and that it was more likely that Mrs Allen was bleeding internally. However, despite the fact that an internal bleed is a life threatening emergency he did nothing to investigate this suspicion further nor did he make any attempt to take action to stop the bleeding. Neither did he inform the doctor on the ward that this is what he thought. Instead he left the nurses and junior doctor on the ward under the impression that they were dealing with a urine problem. He then went home leaving Mrs Allen in considerable pain and distress. On arrival on the ward she told her daughter who was waiting for her that she thought she was dying.

The ward Mrs Allen was transferred to is described as a “High Dependency Unit” but on that day was staffed only by a junior locum doctor, who had only worked at SOTC for one shift before, and nurses. The junior doctor into whose care Mrs Allen was passed to did not look at her records and his only action was to seek help for the supposed bladder problem.  Not knowing what to do he telephoned the on call Anaesthetist and asked another anaesthetist on the ward for help. Neither asked for details of what had happened and neither looked at Mrs Allen’s records. The only advice given was to seek help from an urologist.

His attempts to find help were farcical. It took him nearly an hour to find the correct telephone number to ring. When he called the Princess Royal Hospital, next door, the general surgeon said he could not help as he was finishing work for the day and he was told that the nearest urologist was in Brighton, over 30 minutes away. There was no emergency contact number for the urologist, just the number for his mobile, which was switched off as he was in theatre.

When the urologist finally received the message he drove to SOTC, arriving at around 21.00. In fact, during this whole time, a period of five hours, Mrs Allen had been bleeding. Her daughter’s pleas for help were ignored. Upon arrival at SOTC, where the junior doctor and the on call Anaesthetist were waiting  it took the urologist just 15 minutes to diagnose a bleed and take steps to arrange Mrs Allen’s transfer by ambulance to Royal Sussex County Hospital(RSCH) for emergency treatment.

Mrs Allen arrived at RSCH at 22.25. By that time her condition was so poor she suffered a cardiac arrest and had to be resuscitated before the surgeons there could try to stop the bleed. After two operations they managed to, but by that time Mrs Allen was in multi-organ failure from which she never recovered.

SOTC have accepted that there was delay in diagnosis and seeking treatment. They accepted that communication and record keeping, and record reading, was poor. However, at the Inquest the SOTC staff, specifically three Consultant Anaesthetists, continued to insist that the fact that Mrs Allen was bleeding internally was not obvious and their thinking that it was a bladder problem was reasonable, despite the orthopaedic surgeon who operated and the urologist and surgeon from RSCH who treated Mrs Allen all saying that given Mrs Allen’s condition they would have diagnosed internal bleeding immediately.  An independent expert described the failure to recognise a bleed as “remarkable” and went on to say “it flies in the face of basic medical and nursing training to assume that failure to pass urine after non-urinary surgery is due to urinary retention”. Despite these comments the anaesthetist who discharged Mrs Allen to the ward gave evidence that he did not think he had done anything wrong.

Nicola Wainwright of Leigh Day & Co helped the family prepare for and arranged representation for them at the Inquest. The coroner found “Mrs Doris Allen suffered a major concealed intra-pelvic haemorrhage from a branch of the iliac artery as a result of revision hip surgery on 28 August 2009 at Sussex Orthopaedic Treatment Centre. Failure to diagnose this serious complication for five hours was aggravated by poor communication, both verbal and written, by clinical staff involved in her care. Eventually transfer to Brighton and Sussex University Hospital occurred where despite emergency surgery and intensive care medical complications became overwhelming and led to death on 8 September 2009 from small bowel ischaemia and perforation”.

Despite the acknowledgement of some failings by the SOTC Mrs Allen’s daughter, Janis Allen, and granddaughter, Victoria Lewis remain concerned about the safety of SOTC. Ms Lewis concluded; “having heard the evidence at the Inquest we just do not feel that the SOTC is safe. Our advice to anyone thinking of undergoing surgery there is to think twice. Certainly, they should make sure that they are fully informed of the risks of having their operation there rather than in an NHS hospital with full support and proper back up, including the need to be transferred by ambulance to Brighton should anything go wrong, before making a decision”.

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