Inquest family calls for hospital changes

Thursday 27 April 2017

The family of an elderly woman who died at the Hospital following gall bladder surgery say they were never told how ill she was, and so were unable to say goodbye.

Muriel Mavis Double died on 20 April 2016 at the age of 85 following complications which arose following the removal of her gall bladder, an inquest has heard.

Mrs Double successfully had her gall bladder removed on 11 April 2016.

But the inquest heard that during the operation, damage had been caused to a duct that conducts bile from the liver. Professor William Roche, who conducted the post mortem examination stated that the damage "...caused a leakage of bile which is quite corrosive and damages any tissues it comes in contact with. Bile also carries infection and if untreated, a leakage gives a very poor prognosis."

However, the damage to the duct wasn't noticed and Mrs Double was discharged three days later. She was then taken back into hospital on 17 April as she was suffering from stomach pain, and had developed a fever. She remained in the Rayner Ward for a couple days but, as her condition continually worsened, a decision was made to operate again on 20 April. Sadly, Mrs Double died of a cardiac arrest before she could be brought to the operating theatre.

At the inquest her daughters raised concerns regarding the nursing care their mother had received, citing failure from the staff to communicate and care appropriately for their mother.

One of her daughters, who is a nurse, said: "The nursing care that she received was not up to the standards to my opinion. Some aspects, I felt, were not a great reflection of my profession." She continued stating that the "mixed signals" she and her sister received from the nurses had been "confusing". "The nursing staff didn't seem to echo what we had seen. We could see that she was deteriorating but her drip had been taken down and we never told exactly why. You had information that was clearly saying she was a very ill woman who was unlikely to survive but that was never told to us. Had we known how sick she was, we could have had a different death."

Her sister echoed those feelings saying that on the day before her death, her mother had appeared so unwell she couldn't even talk. "She was in so much pain she couldn’t communicate, she couldn’t even bother to try, from my mother that was unusual. I was extremely concerned about the level of pain she was in and I find it Inexplicable that there was no pain score recorded on that day. She needed fluids, yet her drip had been removed and her drink was left on her right side. It was out of reach as she has no movement on her right side because of a stroke."

"We raised those concerns to the hospital after mum's death but we never had any feedback as a family. It was never expressed to us of what a bile leak could mean to our mother. We were denied saying goodbye to her, she died on her own, in pain because nobody told us how ill she was."

Dr Peter Southall, associate Medical Director told the family that an investigation into the nursing care had been conducted following the death of Mrs Double and that he was happy to go over it with the family at a later date. When asked by the Deputy Viscount Mark Harris why the family hadn't received any feedback on the investigation, he stated that the head of nursing had left shortly after the events for personal reasons which had caused a delay.

He also assured the family of Mrs Double that her case would be on the agenda of a hospital meeting in June. "This kind of meeting happens three times during the year. It is for all medical, nursing and senior managerial staff to attend so that we can discuss the cases where the outcome hasn’t been what we expected and what lessons can be learned from it," he explained.

Furthermore, he added that the hospital's three general surgeons have been asked to produce a local standard procedure for bile duct injury, following recommendations made in an External Case Review Investigation by Doctor Stephen Parker,  from the Isle of Wight NHS Trust. 

The hospital declined to comment further on the case.