Hip replacement patient died after surgeon went on holiday
6:00AM GMT 02 Nov 2012
A coroner has severely criticised a hospital over the death of a pensioner who went in for a routine hip replacement but was left neglected after the procedure when his surgeon went on holiday.
Andrew Cox, deputy coroner for Devon, highlighted a lack of “continuity of care” and failure to “escalate” the treatment as contributing to his death.
A specialist tissue expert was not consulted about the pressure ulcers until it was too late. Mr Moulsdale’s amputation, together with his history of heart problems, brought about his eventual death.
The coroner said the amputation and “tragic outcome” could have been prevented. Poor nutritional supervision and poor communication were also factors.
Mr Moulsdale died at the North Devon Hospital in Barnstaple in August 2010, after being admitted for the initial operation in May.
The inquest in Exeter heard that Mr Treble had gone on holiday after the procedure. Mr Cox said the patient was his responsibility. Mr Treble said: “The operation was unremarkable. I anticipated no problems and thought he would have gone home by the time I returned.”
It was almost three weeks after the operation by the time the surgeon was informed that the patient was still there.
Recording a narrative verdict, the coroner said the pensioner died from complications of a hip operation to which neglect was a contributing factor.
He said: “When Mr Moulsdale’s surgeon returned from holiday it was ten days before he realised the patient was still in the hospital. This is unacceptable medical practice.
“There was a lack of continuity in his care. This is unacceptable for a medium to high risk patient. The need to amputate both lower legs could have been avoided and Mr Moulsdale would not have died when he did.
“The failure to escalate matters here is the glaring omission. Looking at the total picture I find that the failings here were gross. There was an opportunity to provide care that could have avoided this tragic outcome.”
The inquest heard that after his operation, Mr Moulsdale had been given compression stockings to prevent deep vein thrombosis
His son-in-law, David Kearney, said he was concerned that the stockings were too tight and that he had been moved six times between wards, on one occasion because a ward was understaffed.
The inquest was told that the progression of the pensioner’s pressure ulcers, partly caused by the compression stockings, was not well documented, and that a window of opportunity to treat them was missed.
Jac Kelly, chief executive of the Northern Devon Healthcare Trust said: “We are deeply sorry and have conveyed our regret to the family. This incident caused us significant distress and we have learnt from it.
“This was a very sad case with tragic consequences for the patient and his family.”
She said measures had been put in place which would mean that the same thing could not happen again.
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