Coroner Returns Narrative Verdict

Mr David Pattrick of Marks Tey, Colchester, died in Colchester General Hospital in December 2010 following an elective operation to remove his gall bladder. The inquest into the circumstances surrounding his death was opened at the Coroner’s Court in Chelmsford on Wednesday 20 February 2013 and adjourned until Wednesday 27 February, when HM Coroner for Essex, Mrs Caroline Beasley-Murray, returned her verdict.

In December 2010 Mr Pattrick was scheduled for surgery to remove his gall bladder following an acute attack of cholecystitis (an infection of the gall bladder) three months earlier, which was treated with intravenous antibiotics. However, because of this attack, Mr Pattrick had a higher than usual risk of a difficult operation.

Mr Pattrick’s operation was carried out by a specialist registrar on 21 December 2010. However, the operation became technically difficult for the registrar, and during the procedure he sought advice from two different consultants; firstly from the emergency on-call consultant; and then from another consultant, although neither of these consultants was “scrubbed”. Only a partial removal of the gall bladder could be achieved, which meant that Mr Pattrick was at increased risk of further infection.

There is no record that Mr Pattrick was reviewed by a doctor on the night of his operation. He was seen the following day – 22 December - by the specialist registrar on two occasions. However, on 23 December the specialist registrar was off duty, and there was no consultant who had accepted responsibility for Mr Pattrick. This left a Foundation year 1 doctor and a nurse practitioner to carry out the morning ward round. During the day Mr Pattrick complained of severe abdominal pain but, despite the repeated use of pain-killers, the level of Mr Pattrick's pain did not seem to have been recognised. At about 3pm on 23 December Mrs Pattrick insisted that her husband be seen by a doctor because of the severe pain he was in, and the year 1 doctor attended him. Blood test results showed that he was likely to be suffering from an infection.  Mr Refson, the consultant laparoscopic surgeon who assisted the Coroner, gave evidence that at that stage more senior help should have been sought; had that been done the outcome may have been different for Mr Pattrick.

Mr Pattrick, 69, was discovered later that evening collapsed on the floor of the lavatory of the recently-opened Mersea Ward at Colchester General Hospital. Efforts to revive him were unsuccessful. Dr Rouse, who carried out the post-mortem, gave his opinion that the causes of Mr Pattrick's death were septicaemia and paralytic ileus as a result of the operation on his gall bladder.

In giving evidence to the inquest, Professor Roger Motson, who was in charge of the clinical team at the time, said the confusion over who was accountable for Mr Pattrick was the result of NHS targets. He said he did not approve of the introduction of a pool list to try to treat patients, but that unfortunately it was a part of the current NHS.

The Court also heard further from Mr Refson, who the Coroner had asked to give an independent overview of the matter, that there were several areas where the care given to David Pattrick by Colchester General Hospital could have been improved upon:

• Mr Pattrick should have attended a follow-up appointment following his admission in September 2012 before being scheduled for surgery
• The consent procedure did not fully explain the risks of the operation to Mr Pattrick
• There was confusion over who was clinically responsible for the care of Mr Pattrick – no consultant took ownership
• He would have had a consultant “scrubbed” during the operation
• A post-operative surgical review was not carried out
• On the first post-operative day there was very good evidence to suggest that Mr Pattrick was septic – which on its own can be a marker of serious infection
• Imaging was required by 9.00am on the second post-operative day, when it was even more evident that David Pattrick was seriously ill
• The Foundation year 1 doctor should have realised the severity of Mr Pattrick’s situation and escalation to a senior doctor should have occurred

HM Coroner for Essex and Thurrock, Mrs Caroline Beasley –Murray, in giving her verdict, said that the Court accepted in its entirety the evidence of Mr Refson. She went on to make four findings:

• There was insufficient pre-operative counselling
• There was a failure of a consultant to take overall responsibility for Mr Pattrick
• There was poor supervision of junior trainees
• There was a failure of junior staff to escalate to senior surgeons

She found the cause of Mr Pattrick’s death to be from natural causes, but in giving a narrative verdict said that there were serious failings in the care that Mr Pattrick had received whilst in Colchester General Hospital. She commented that she was pleased to see that Colchester General Hospital appeared to have learnt lessons from Mr Pattrick’s case and thanked them for their assistance in the run-up to this matter. She added that Mrs Susan Pattrick, Mr Pattrick’s widow, had conducted herself with great dignity throughout the proceedings and that Mr Pattrick was clearly a much loved gentleman.

Julian Wilson said “It was particularly helpful for Mrs Pattrick that the Coroner gave a narrative verdict which identified the serious failings at Colchester General Hospital. One of Mrs Pattrick’s main concerns is that no one else should have to go through her experience. By persisting in her request for an inquest to take place she has brought these failings to light.”