Coroner criticises Queen’s Hospital for mistakes that led to Elm Park grandfather’s death
PUBLISHED: 07:00 08 September 2017 | UPDATED: 09:13 08 September 2017
A senior coroner has filed a damning report to the director of public health after a botched radiological procedure led to the death of a 77-year-old grandfather.
Nadia Persaud was so concerned by mistakes made by Queen’s Hospital doctors prior to Kevin Mann’s death, that she has alerted officials to prevent further deaths.
Kevin, of Cavendish Avenue, Elm Park, died a year ago yesterday (Thurs) after his lungs failed as a result of what Barking, Havering and Redbridge University Hospitals Trust (BHRUT) dubbed “a clinical governance gap”.
The lifelong West Ham fan had an operation to fight oesophagal cancer at the Rom Valley Way hospital on May 23 last year.
Four days later he underwent a contrast study, where he swallowed a chemical solution to help make X-rays clearer in order for doctors to measure his throat’s recovery.
Son Simon, of Woodford Green, told the Recorder: “It was a big surgery and he was on the table for more than 10 hours, so of course he wasn’t in a great state but he had come through it – the surgeon was happy with how the procedure had gone.”
Unfortunately, the chemical solution entered his lungs, and Kevin died of respiratory failure on September 7.
At an inquest in June this year, Ms Persaud found a number of mistakes had been made by staff in Queen’s Hospital’s radiology department during Kevin’s treatment.
An independent radiologist consulted by the coroner determined that Mr Mann’s left lung was obviously collapsed in an X-ray taken before the contrast swallow procedure, and that this X-ray had never been looked at.
If it had, the consultant said, the swallow procedure should not have gone ahead.
The coroner also determined that radiologists had become aware of fluid entering Kevin’s lungs mid-procedure and, instead of abandoning it as per suggested medical practice, continued.
Simon added: “I’m a former Campion schoolboy, I still have friends that live in the area and I think they deserve to know that these mistakes are being made and that it can be dangerous.”
At the inquest, futher concerns were raised about the lack of documentation surrounding Kevin’s contrast swallow.
The radiology department was unable to produce any records stating the quantity of contast solution, called Visipaque, he had been given.
And Ms Persaud was also troubled by evidence that suggested that no changes had been made to Queen’s Hospital’s contrast swallow procedures since Mr Mann’s death.
She concluded: “The incident occurred over a year ago. Despite clear concerns being raised by the consultant surgeon on May 27, 2016, there had been no adequate review of the Visipaque procedure policy by the date of the inquest hearing.”
This led her to submit a regulation 28 report to both the director of public health and the Care Quality Commission, highlighting how the trust could prevent future deaths.
At the inquest, 50-year-old father-of-one Simon told the coroner: “It’s my view that during the sip test on May 27, a fatal lack of care took place.
“Whether that was through negligence, carelessness, Friday night time pressures or a lack of training is what needs to be decided.”
Dr Nadeem Moghal, BHRUT’s medical director, said the trust had done all it could to learn from Mr Mann’s death.
He said: “We would like to apologise to Mr Mann’s family for the distress caused by his death, and we acknowledge that we fell short of the high standards we set ourselves in our treatment of him.
“We have worked extremely hard to tackle the issues which were highlighted by the inquest, and have responded to all the concerns raised by the coroner.”
Chief among these, the trust has introduced a new way of administering Visipaque swallows to ensure they fall into line with national standards, and that all staff are fully trained in the new process.
Dr Moghal added: “We are sorry for our shortcomings on this occasion, but believe that the learning we have been able to take forward means we are providing better care for our patients now and in the future.
“We have invited Mr Mann’s family to meet with us to discuss their concerns.”