Staff at hospital already in special measures failed to recognise basic signs and symptoms of deterioration.
The coroner at the inquest into the death of Anthony Baker, a 61-year-old father of three from the Isle of Sheppey, yesterday identified a number of failings into his care that led to his death at Medway Maritime Hospital.
The three-day inquest, held at the Mid Kent and Medway Coroner’s Court, heard how Mr. Baker died on 31 March 2014 having suffered a cardiac arrest. He thereafter suffered multiple organ failure after junior doctors and nurses failed to recognise signs of internal bleeding and to diagnose a false femoral aneurysm.
Shortly before the inquest, Medway NHS Foundation Trust accepted that there were failures in Mr. Baker’s care and that these caused his untimely death. The Trust has been in special measures since July 2013 following the Keogh Mortality Review.
In her conclusion, the coroner Ms Kate Thomas, said: “Anthony Baker underwent an angiogram and stenting procedure following which he developed a false aneurysm which ruptured. Although he displayed a number of symptoms from which a rupture could have been diagnosed over a period of 15 hours there was a failure to do so. Thereafter Mr. Baker went into cardiac arrest due to internal bleeding and, despite surgery, he declined and died on 31st March 2014 at Medway Maritime Hospital.”
Mr. Baker, who was a self-employed driver trainer, was admitted to the Medway Maritime Hospital on 22 March 2014 and treated for cardiac symptoms. Later that day, he was admitted to intensive care for kidney problems. Over the course of the next eight days he responded well to treatment and was transferred from intensive care to the ward on 28 March.
Shortly after his transfer to the ward, Mr. Baker developed significant pain, unremitting despite morphine and other painkilling medication, and other signs of bleeding. However, these signs went unrecognised until 30 March, when he suffered a cardiac arrest. Emergency surgery was performed to treat a ruptured false aneurysm in his left femoral artery, where a massive haematoma was discovered.
Following surgery, Mr. Baker returned to intensive care where he suffered multiple organ failure. A decision was subsequently made to withdraw treatment. Mr. Baker died at 12.31pm on 31 March 2014.
It was found that the false aneurysm had been developing from the time that Mr. Baker’s pain started, but the nursing and medical staff failed to recognise the basic signs and symptoms of a deteriorating patient who was bleeding, namely pain, a drop in blood pressure, and poor urine output.
The inquest also heard that:
- There was a lack of awareness on the ward about the complications associated with angiography, and appropriate monitoring for such complications. There is still no list of potential complications available to ward staff.
- The Trust is now taking steps to follow the latest guidelines which advocate using the radial artery for angiograms, rather than the femoral artery, due to less complications.
- There was no weekend cover provided by cardiology consultants at weekends that junior doctors could access. This has since changed and a consultant cardiologist is available at the hospital on Saturday and Sunday mornings.
- Culturally, junior doctors and nurses at the hospital did not want to escalate problems to senior doctors and consultants, and there was a reluctance to call people out of hours. Nurses were also found not to escalate concerns to a consultant about junior doctors’ management of conditions. Steps have been taken to change this culture to encourage everyone to report concerns as soon as possible, and the Trust’s induction programme tells new joiners to escalate any instances of concern.
Mr. Baker’s widow Jane Baker says: “Tony, my husband of 31 years, was my world. He was a fabulous father to our three sons, Andrew (30), Stephen (28) and Christopher (17) and our lives have been ripped apart since he was stolen from us in March 2014. It is so difficult to accept his death, largely because it happened as a result of others’ mistakes. Tony was bleeding and the staff at Medway didn’t recognise this until it was too late.
“I am relieved that the Coroner has identified failings and I sincerely hope, as I know would Tony, that as a result of the changes made at the Trust no other person has to go through this trauma again.”
Following Mr. Baker’s death, it was discovered that Medway Maritime Hospital had not performed a full untoward incident investigation. A Patient Case Safety Review (PCSR), which decides if an incident is serious and requires further investigation, was completed by a matron. The medical director did not approve the incident as serious and so a full investigation did not happen. The PCSR, completed in April 2014, was withheld from the family until February 2015. It recommended that guidelines be produced for management post angiogram and the care plan improved to include a box for checks to be completed for up to 6 hours after, with daily site checks thereafter.
Dawn Treloar, medical negligence solicitor at Hodge Jones & Allen representing the Baker family said: “Medway NHS Trust has already actioned some of the shortcomings identified in our evidence to the inquiry into Mr. Baker’s untimely death. We sincerely hope that these actions are effective in improving patient safety, and that any further training issues are promptly identified and met. It is essential that lessons are learned and incidents such as this are avoided in the future.”
The Baker family was also represented by Pravin Fernando, Counsel of Serjeants’ Inn Chambers.
For further information, or to arrange an interview with Dawn Treloar, please contact: Clare Rice, Black Letter Communications, on 020 3567 1208 or firstname.lastname@example.org
Notes for Editors:
Hodge Jones & Allen was founded in 1977 in Camden and has 200 staff based in Euston NW1. The firm practices personal injury, clinical negligence, civil liberties, family law, wills and probate, housing, dispute resolution, criminal defence and serious fraud.