Lister Hospital found ‘grossly negligent’ at inquest of Letchworth woman

The Coroner for Hertfordshire said if her care had been escalated apporopriately it is likely that Mrs Soneji would have survived. Picture: Dipesh Soneji (Image: Archant)

Coroner Geoffrey Sullivan heard evidence from a surgeon, doctors and representatives for the East and North Herts NHS Trust yesterday at the Old Courthouse in Hatfield, to conclude a cause of death of Taruna Soneji – who had elective surgery to remove her gallbladder in December 2016.

The inquest heard that Mrs Soneji passed away due to a number of factors – including a lack of post-operative medical care when bile leaked into her system.

Following an ‘unremarkable’ surgery at Lister on December 8, 2016, Mrs Soneji was returned to a ward.

When surgeon Sanjay Gupta checked on her, she complained of abdominal pain, but otherwise appeared to be recovering well.

However, the inquest was told that her condition began to deteriorate rapidly the next day, with low blood pressure and an extremely high heart rate. At this point, nursing staff made attempts to alert members of Mr Gupta’s surgical team, with no success.

The inquest was told that during the staff handover, night staff were not made aware of Mrs Soneji’s condition – which meant she was not seen by a doctor until 10.50pm that night.

A junior doctor was asked to tend to Mrs Soneji, and said he noticed she was “in pain, holding her abdomen and looked very unwell”.

After looking at her blood pressure and heart rate again, he prescribed two bags of fluids, but felt he needed to get some advice from a more senior doctor.

Dr Georgios Vlachos – a specialist in vascular surgery, and the most senior person on call at the time – attended Mrs Soneji at 11.47pm and requested a full blood count to rule out a bleed.

Results for the blood count were available during the early hours of December 10, 2016. They showed a normal blood count, but high levels of inflammation, the inquest heard.

Dr Vlachos admitted at the hearing that he did not look at her observational chart and “that was a mistake”.

He is being investigated by the General Medical Council over Mrs Soneji’s care, and said he had since taken on additional training.

Mrs Soneji was not seen again until the next morning, and her blood count results were not discussed until considerably later than they were made available.

When Mr Gupta returned the hospital on the morning of December 10, the inquest heard how he quickly recognised Mrs Soneji’s condition and did a CT scan which showed a leak.

She was initially too weak for surgery but when her condition improved enough, Mr Gupta drained a litre of bile from her abdomen. He could not locate the source of the leak.

Following a process of elimination, coroner Mr Sullivan ruled that the likely source of the leak was the gallbladder bed.

Mrs Soneji was returned to intensive care, but was starting to go into multiple-organ failure.

Mr Sullivan said: “When I look at all the evidence, which included a very thorough and frank review conducted by the hospital, it’s clear to me a number of matters contributed to Mrs Soneji’s death on December 12.

“There were non-escalated observations over the course of December 9 and 10.

“There was a lack of medical follow-up and it’s clear that this might have led to a delay in diagnosing the bile leak and delaying her treatment.

“A number of surgeons, including Mr Gupta, were of the view that where there is a bile leak, appropriate and prompt treatment usually leads to survival and mortality is exceptionally rare.

“Evidence suggests that the observations at the time should have been escalated, but were not – resulting in a delay in diagnosis.”

He concluded: “My view is that the evidence does support that there was a gross failure to provide basic medical care. The need for post-operative care was obvious.”

During the inquest, NHS trust members outlined an action plan that is now in place to ensure improvements are made – including new electronic records of observations which must be filled in hourly, and a new system for calling senior medical staff and mandatory end-of-day checks.

Following the hearing, Mrs Soneji’s son Bhavin told the Comet: “I’m content that it has been recognised that there was negligence on the part of the trust. This is the beginning of the end. It allows us as a family to have an element of closure.”