QA Hospital: Coroner issues warning to Portsmouth Hospitals University NHS Trust after patient dies following weight loss surgery

Susan Evans, 55, returned to hospital with stomach pain just two days after having undergone gastric bypass surgery at Queen Alexandra Hospital on July 11, 2023, it was heard. Her return to hospital was the first day of industrial action and the coroner said there was no specialist weight loss nurse on duty, and Ms Evans was not seen by a senior doctor.

Ms Evans was discharged but returned to hospital days later by which point she was 'extremely unwell' and her condition continued to deteriorate until she died in August last year. Now, an inquest into her death heard of several 'failures' by Portsmouth Hospital University NHS Trust which 'contributed more than minimally to her death'.

Coroner Sally Olsen said Ms Evans underwent elective Roux-en-Y gastric bypass surgery on July 11 last year. The surgical procedure helps with weight loss by reducing the size of the stomach and rerouting the small intestine.

An inquest heard that the surgery 'went to plan' and measures were taken to avoid the possibility of an 'anastomotic leak', a but recognised complication of gastric bypass surgery. It was said that Ms Evans initially 'recovered well' but experienced stomach pain in the early hours of July 13, which was the first day of a junior doctors’ strike.

Ms Olsen, assistant coroner of Hampshire, Portsmouth and Southampton, added: "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 [that day] and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak."

It was heard that the night nursing team, who administered pain relief, were 'unaware' of the latter requirement. Ms Evans was also not seen by a member of the bariatric team - a group of medical professionals who work together to treat patients with obesity - prior to her discharge.

The patient left the Portsmouth hospital 'in a degree of pain' and was readmitted two days later. By this time, she was 'extremely unwell' with sepsis and had to undergo remedial surgery on July 15 before a further operation some ten days later.

The coroner said: "Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on August 12, 2023.

“It is likely that, if she had been seen by a member of the bariatric team on July 13, 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."

In a prevention of future deaths report, addressed to the Portsmouth Hospital NHS Trust, Ms Olsen said her inquiries revealed several 'matters giving rise to concern'.

The coroner said that under Queen Alexandra’s post-operation care guidance, a bariatric specialist nurse, consultant or registrar, was required to carry out a daily review on patient of weight loss surgery. And, a senior doctor was also to see a patient if the experienced abdominal pain within two hours of attending hospital.

The coroner said: "Neither the written nor informal policy set out above were followed in Ms Evans’ case. She was not reviewed by a member of the specialist bariatric team at any point on day two after surgery and the pain she experienced from the early hours of July 13, 2023 was not escalated to a senior doctor at all.

"The inquest heard evidence that medical staff who were not part of the specialist bariatric team were unlikely to appreciate the significance of pain. The failure to follow policy contributed more than minimally to Ms Evans death and is therefore a matter of concern."

The trust have until February 7 to respond to Ms Olsen.

Dr John Knighton, chief medical officer at Portsmouth Hospitals University NHS Trust, said: “I am very sorry for the care we provided to Susan and would like to send my deepest condolences to her family. We continue to fully cooperate with the Coroner and will be responding to the issues raised during Susan's inquest.

“A full internal investigation has also taken place and we are taking action to improve our care especially the communications between clinical teams and our patients when they leave hospital.”

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