Patient died in hospital after delay to operation

Herne Bay Times - 22 September 2005;

Pensioner Edith O’Neill died after her bowel burst following a routine hernia operation an inquest heard.

Coroner Rachel Redman was told the 67 year old grandmother from Shepherdsgate Drive, Herne, spent a day in agony as doctors delayed performing a second emergency operation.

Miss Redman said she had “serious concerns” about the East Kent Hospitals NHS Trust, which had been using holiday cover to hit government targets.

The inquest at Ashford on Thursday heard that Mrs O’Neill’s consultant, Mr Khushal was on holiday. His place was taken by Mohammed Jalilullah using a “buddy arrangement” where doctors take over their colleagues patients.

Mrs O’Neill went into Ashford’s William Harvey Hospital on Tuesday 26th April and had her hernia operation the next day. During the operation the blood supply to her small intestine was cut off. The following day the wall of her bowel burst, causing a huge infection. Although she complained of pain, staff failed to alert doctors.

Two days later, on Friday April 29, Nurgat Raul, the head of the consultancy team rushed Mrs O’Neill into the theatre for an emergency operation at 6pm. But she died in intensive care the following evening at 8.25 pm.

Mr Raul said it was the worst case of peritonitis – an inflammatory disease – he had seen.

The inquest heard that surgeons were aware of problems at noon on the Friday but had failed to act immediately.

The coroner asked if Mrs O’Neill might have survived if she had been operated on as soon as the doctors were aware.

Nr Raul said: “That would have been detrimental to her. She would not have survived five minutes if we’d done that.”

Miss Redman also asked: “How can it be that this woman was admitted to hospital when her consultant was on leave?”

Mr Raul replied: “Waiting list targets. If the (East Kent Hospitals NHS) Trust doesn’t comply the Trust gets penalised.”

Miss Redman said she was “seriously concerned” about constraints set by government targets which encouraged hospitals to accept patients even when their consultants were on holiday.

She also expressed surprise that Mr Raul didn’t know who was in charge of Mrs O’Neill.

She added that a “window of opportunity” had been missed at noon on Friday April 29.

There was also some debate about the qualifications of stand-in doctor Mr Jalilullah although these fears were later proved to be unfounded.

A post-mortem examination at Greenwich revealed that Mrs O’Neill had died of an infection caused by a perforated bowel after her hernia operation.

Miss Redman said: “Mrs O’Neill died as a result of an unattended consequence of a necessary treatment.”

After the inquest solicitor Nick Fairweather of Harman & Harman, representing Mrs O’Neill’s long-time partner Brian Seabrook, said: “This is a tragic case. Mrs O’Neill attended the hospital for elective surgery which should have been a straightforward operation. But it went wrong because of a breakdown in the system. She did not have the immediate attention of the consultant in charge of her care.” He added: “It is the family’s hope that the Trust can learn from the mistakes of this case. An understandable wish to cut waiting lists should not compromise optimal patient care.” He said the family was making up its mind whether to launch a civil action against the Trust in the courts.

Malcolm Stewart, the deputy medical director for East Kent Hospitals NHS Trusts said: “First we would like to offer our sincere condolences to the family of Edith O’Neill. As we understand that the family has taken further independent legal advice concerning her care we are unable to go into specific details about this case,” he added.