Failings at a hospital contributed to the death of a 55-year-old woman who suffered abdominal sepsis after weight loss surgery at the time of a junior doctors’ strike, a coroner has said.
Susan Evans returned to Queen Alexandra hospital in Portsmouth, Hampshire, with stomach pains two days after undergoing elective gastric bypass surgery.
She was sent home without being seen by a member of the specialist bariatric team or a senior doctor, though hospital policy says this should happen, and became seriously unwell.
Evans returned to hospital and underwent two further operations but died a month after the original procedure.
In a prevention of future deaths report, the coroner Sally Olsen said neither written nor informal policies had been followed and failures “contributed more than minimally” to Evans’s death.
She said that on 11 July 2023, Evans had undergone gastric bypass surgery. The surgery went to plan and appropriate measures were taken to avoid the possibility of an anastomotic leak, a rare but recognised complication.
Evans initially recovered well, but experienced abdominal pain in the early hours of 13 July 2023, which was likely to have been caused by an anastomotic leak.
The coroner highlighted that it was the first day of a strike by resident doctors, formerly called junior doctors. She said: “Unrelated to this, the hospital only had the equivalent of one full-time specialist bariatric nurse, who was not on duty.
“Contrary to Queen Alexandra hospital’s written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team on 13 July 2023 and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak. The hospital at night nursing team, who administered pain relief, were unaware of the latter requirement.
“In addition, Ms Evans not seen by a member of the bariatric team or any doctor prior to her discharge from hospital on the morning of 13 July 2023. Ms Evans was still in a degree of pain when she left hospital.
“She was readmitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak. She underwent remedial surgery on 15 July 2023 and a further operation was required on 25 July 2023.”
Her condition deteriorated, and she died at the Queen Alexandra hospital on 12 August 2023. The coroner said: “It is likely that, if she had been seen by a member of the bariatric team on 13 July 2023, she would have been kept in hospital and would have been operated upon sooner. The failures identified contributed more than minimally to her death.
“Neither the written nor informal policy were followed in Ms Evans’ case.”
Portsmouth hospitals university NHS trust has until 7 February to respond to the coroner, who said it should set out any action it had taken or proposed to carry out and include a timetable for action – or explain why no action was proposed.
