New guidelines in place following man’s death at Hinchingbrooke Hospital
- Credit: Archant
The foundation trust which runs Hinchingbrooke Hospital has introduced new guidelines following the death of a man from Godmanchester.
The North West Anglia NHS Foundation Trust said it had introduced new policies, after 31-year-old Adam Hurst died at the hospital in December.
An inquest held at Huntingdon Law Courts on November 5-6 heard how Mr Hurst's wife Vicky, had taken him to the accident and emergency (A&E) department on December 7, 2018, at about 7pm after he had complained of severe abdominal pain.
Mr Hurst, who had an umbilical hernia since birth, had previously visited his GP complaining about abdominal pain 11 days before he was taken to hospital, but was sent home as the GP thought he was suffering from acid reflux.
Whilst in A&E, the hearing was told how Mr Hurst's family were unhappy with the care he received, saying he was left in "extreme pain" and was ignored by members of hospital staff.
Due to a shortage of beds on the 'majors unit', Mr Hurst was given a bed in the 'minors unit' whilst he waited for a vacant cubical.
Mr Hurst was then given five milligrams of morphine, along with other pain killers, but the inquest heard how the pain relief wasn't helping.
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At about 7.45pm, he was moved to the majors unit, after a cubical became available.
"Personally, I felt a cautious approach was better when it comes to controlled drugs," Mr Shashank Ranjan, consultant in emergency medicine at the hospital, told the inquest.
Mr Ranjan explained how he thought they were dealing with a suspected strangulated umbilical hernia, after finding out about Mr Hurst's medical history.
However, after examination, Mr Ranjan explained that he "wasn't convinced" that it was an umbilical hernia, and that he had suspected that it could be a diaphragmatic hernia that was strangulated.
The inquest heard that as Mr Hurst was about to have a CT scan, the fire alarm had sounded in the radiology department, meaning there was delay in getting him to the scan.
At about 9pm, Dr Andriy Solodkyy finished in theatre and was walking to see Mr Hurst to assess him for possible overnight surgery.
Dr Solodkyy said: "When I found out I called the anaesthetist and went back to the ward as the team has to meet up to discuss possibilities and complications before any surgery.
"As I was walking towards the theatre, I heard the crash alarm go off, and when I got there Mr Hurst had had a cardiac arrest and the team were doing CPR."
The inquest heard how Mr Hurst was given CPR for 45 minutes, but he was pronounced dead in the early hours of the morning on December 8. It is understood that Mr Hurst had a second hernia in his abdomen which strangulated and caused him to suffer a cardiac arrest.
Assistant coroner, Rosamund Rhodes-Kemp said: "The cause of death was intrathoracic and abdominal hermitage, a diaphragmatic hernia and a ruptured spleen."
She gave a narrative conclusion saying: "It is not possible to say that, on the balance of probability, earlier surgery could have altered the outcome due to the rarity and complication of the condition."
The North West Anglia Foundation Trust says it has introduced new guidelines, including pain management and communication for staff members.
Vanessa Gilbert-Gomez, clinical risk advisor for the trust, told the inquest that a "proper pain assessment would have caused less distress to the family".
She explained that 11 recommendations had been given to the trust, including pain management training sessions for staff on the A&E ward which will teach that "pain is what the patient says" and to not undermine the amount of pain that patients are in.
Another recommendation was individual sessions with all staff members regarding communication, after Mr Hurst family said they were treated "unfairly" and "his pain wasn't taken seriously".
Dr Kanchan Rege, medical director for North West Anglia NHS Foundation Trust, which runs Hinchingbrooke Hospital, said: "We would like to offer our condolences to the family of Mr Hurst during this difficult time. We have now introduced a single trust-wide acute pain guideline and provided additional training to staff on pain management and communication skills."