Ipswich: Grandmother’s death sparks investigation into care of critically-ill patients at Ipswich Hospital, inquest hears
11:00 19 August 2014
Ipswich Hospital has made major changes to the way it cares for critically-ill patients after a 77-year-old grandmother died following a routine operation to remove gall stones, an inquest has heard.
Pearl Underwood, of Campbell Road, Ipswich, went into the hospital on February 28 last year after several months of reporting pain in her abdomen.
Last night her family said they were “relieved” but “sorry” it had taken the tragedy to bring about changes to the way patients with deteriorating conditions are treated.
The inquest at Ip-City Centre, Ipswich, heard how most patients are able to go home the same day following the operation despite it being classed as “major”.
But Mrs Underwood, who has been described as “fit and healthy” and also worked as an activities assistant, died two days later.
At the time of her death “outreach” intensive care medics were not available between 10pm and 8am to communicate with ward nurses about the best ways to help patients whose conditions were worsening.
Sarah Seeley, matron, said at the inquest: “The deterioration of patients is a significant problem, it’s registered as one which we are trying to recognise.
“Now we have in place a 24-hour critical care outreach nurses team which supports the ward nurses which helps to develop the early escalation so we can get the right system in place.”
Dr Barbara Buckley, the hospital’s medical director, said there were “several areas” that needed improvement and that Mrs Underwood’s condition should have been identified as being “appropriate” for intensive care sooner.
She added: “The early warning system (for patients) is key and we are putting in a system which calls them (doctors) automatically when the system triggers a certain level which they have to act on.”
She added that there should also be a “much lower threshold” for when intensive care medics are notified.
The new system electronically messages doctors automatically when a patient’s Modified Early Warning Score reaches a high enough level.
Suffolk coroner, Dr Peter Dean, said: “In an ideal world there would have been, clearly, a transfer to intensive care and it did not take place at the earliest possibility. It is undoubtedly the case if transferred to critical care earlier there would have been further attempts to support the organ systems.”
He recorded a narrative verdict saying: “There was a serious but uncommon complication following the operation, the critical transfer was not escalated at an early opportunity while whether it would have affected the outcome cannot be established.”
He said the only “reasonable cause” of death was as a result of Systemic Inflammatory Response Syndrome.
The family released a statement through their solicitor Julian Wilson. He said: “The family have asked me to say that they are grateful for the care that coroner Dr Dean has taken over this inquest. They are relived it is over but disappointed that it took so long to occur.
“They are pleased to see that the hospital have instituted changes but are sorry it has taken such a tragedy to bring them about.”