Ipswich: Grandmother’s death sparks investigation into care of critically-ill patients at Ipswich Hospital, inquest hears

Pearl Underwood who died after going in for a routine operation to remove gallstones. Pearl Underwood who died after going in for a routine operation to remove gallstones.

Tuesday, August 19, 2014
11:00 AM

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.

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Julie Beaumont with her mum Pearl UnderwoodJulie Beaumont with her mum Pearl Underwood

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.”

6 comments

  • Next time you visit Ipswich Hospital especially round the out patients area..just take a minute and watch how many paper carriers there are moving around!!

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    waspie

    Thursday, August 21, 2014

  • I know of an older lady in late 70'searly 80's having a mastectomy and discharged the same day, with drains etc, needed to return to hospital next day due to too much blood in drain, why wasn't she given adequate time in hospital. Seems as if hospital care is nothing more than a conveyor belt , Hope I don't need any care of this type in my twilight years.

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    Footyfan

    Wednesday, August 20, 2014

  • my mum just had this op done and was released 8 hours after waking from the surgery, it is very wrong they need to keep people longer after major surgery

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    jlumpkin

    Wednesday, August 20, 2014

  • not just the old . I am 48 and went in for heart problem . now my paper work states headaches confused.com I have ask for a different hospital to advise me

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    Lee mundy

    Tuesday, August 19, 2014

  • Ipswich Hospital is like a lottery for the elderly.

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    Driven Roundabend

    Tuesday, August 19, 2014

  • Time and again they say we will do better next time. Not good enough. Get it right first time. I lost my Mum but trying to get them to admit erros is like asking for lottery numbers

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    Homeland warrior

    Tuesday, August 19, 2014

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