Hinchingbrooke death: ‘Alarm bells should have been ringing’

A FAILURE to diagnose a bowel infection quickly enough led to the death of a cancer patient at Hinchingbrooke Hospital, an inquest heard.

The hospital has compiled a Serious Untoward Incident (SUI) report since the death of Wendy Hopkins, 70, on February 8, and will include her case in a review of colorectal services at the hospital.

Among the internal report’s findings was that two different pain scoring scales were being used by nursing and surgical teams – one grading a patient from 0 to 3, the other from 1 to 10 – meaning that staff were misunderstanding each other and patients were sometimes being left in pain.

In July the hospital agreed to submit to an external review of colorectal practice after coroners raised concerns over the death of two women who had undergone surgery on the unit.

Speaking at the inquest, Mrs Hopkins’s husband Roland hit out at the care his wife received, saying she had been left in severe pain and that he had twice seen her lying in blood-soaked sheets when he visited in hospital.

Dr Sam Bass, deputy coroner, said too much weight had been given to the possibility of a chest infection, and that abdominal abscesses should have been found earlier.

Given her medical history, “a higher index of suspicion” should have been used and “alarm bells should have been ringing” when she failed to recover, he said.

He gave a narrative verdict, ruling: “She died from a known complication of a procedure that was not identified or acted upon in a timely manner.

“This is not a criticism of the clinicians involved: it is merely a statement of fact.”

Mrs Hopkins, of Beachampstead Road, St Neots, had been admitted to hospital on October 12, her 47th wedding anniversary, for cancer surgery to remove a part of her bowel, but developed sepsis and did not leave hospital again.

She underwent two further operations to clean and repair her bowel, spending 90 days in intensive care before her death.

Surgeon Bessam Bekdash said that Mrs Hopkins’s condition was “very, very rare” and that a perforation or leak was “easier to diagnose in a virgin bowel than in one which has had surgery”.

Jan Palmer, Hinchingbrooke’s associate director of women’s and elective services, said the SUI report had flagged up areas for improvement, most notably the conflict in pain grading systems.

She said: “Where for us [a particular pain score] would warrant treatment, to some surgical members of the team it would mean it is nothing we need to treat.

“This highlighted a large issue for us that had not been brought up before.”

Staff cover was being reviewed to ensure patients and families had better access to doctors and specialist nurses at visiting times and on weekends, she added.

Dr Richard Dickinson, medical director at Hinchingbrooke, extended his sympathies to Mrs Hopkins’s family after the inquest and said that patient safety was the hospital’s “top priority”.

He reiterated that the hospital would follow recommendations made by the Royal College of Surgeons’ independent review, and that in the meantime most complex colorectal surgery would be relocated to Addenbrooke’s Hospital, Cambridge.