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Hospital admits ‘mistakes’ in its treatment of former nurse
There was communication failure, surgeon tells inquest into patient’s death
A RETIRED nurse died at the Royal Free Hospital after doctors failed to diagnose blood poisoning in time to save her, an inquest heard.
Professor Marc Winslet, head of surgery at the Hampstead hospital, admitted “mistakes” were made in the care of Maria-Luz Purvis, 75.
He told St Pancras Coroner’s Court on Tuesday: “If only things were as clear as they are in textbooks and the internet our lives as surgeons would be much easier. It’s all about the subtleties. It was definitely a communication error.”
Spanish-born Mrs Purvis, from Ellerdale Road, Hampstead, died in September from an infection caused by a tear to her bowel, eight days after she had undergone a hysterectomy.
Prof Winslet said that had doctors treated the perforation on the day the possibility of the problem was first flagged up she may have survived.
Instead advice from a radiologist following a scan that the possibility of a perforation needed to be “excluded” was rejected.
The court heard that a junior doctor decided she was suffering from chest problems and, against hospital guidelines, failed to seek the opinion of more senior doctors.
As a result, Prof Winslet finally saw Mrs Purvis more than 48 hours later. She died the following day having sustained two small holes in her small intestine.
Doctors in the witness stand were quizzed over why they had failed to spot signs of peritonitis in the days leading up to her death.
The court heard Mrs Purvis was more susceptible to bowel perforations because she had undergone surgery on her bowel 20 years earlier.
Gynaecologist Heather Evans, the consultant in charge of her care, told the court she had been kept in the dark about the radiologist’s advice and the decision taken by the junior doctor.
Miss Evans said while the possibility of a bowel perforation had been “in the back of my mind” she had put the pensioner’s symptoms down to chest problems. She admitted Mrs Purvis would have been moved to the top of her operating list immediately had she known about the radiologist’s advice.
Miss Evans said: “Looking at it, Mrs Purvis only had a temperature once, her pulse was steady and her blood pressure was stable. She was tolerating fluids and she had opened her bowels. You could touch her abdomen. Signs of peritonitis weren’t there and there were other signs, for example, her chest.”
Vanessa Purvis, the patient’s daughter, said: “I’m not a doctor but with her symptoms, her abdomen was hugely distended, the weakness, dizziness, nausea, the colour of her skin, it doesn’t answer my question. If people with her surgery [the bowel cancer surgery] are predisposed [to perforations], why then focus on the chest and not the bowel?”
She asked whether her mother would still be alive had the hospital guidelines been followed.
Prof Winslet said: “It was definitely communication failure. I would have expected that surgical registrar [the junior doctor] to talk to someone who may have been able to throw some light on her condition. And also she wasn’t seen the following morning by a consultant. That’s where I think the mistakes were made.”
But he added: “If she’d gone for surgery earlier it might have made a difference but could diagnosis have been made at that time? It’s difficult.”
Dr Reid ruled Mrs Purvis died from “severe sepsis caused by bowel perforation” and, returning a narrative verdict, ruled it was an “accidental adverse healthcare event”.
A hospital spokeswoman said later: “We are carrying out a detailed investigation into the case to ascertain whether there are any wider lessons to be learned.” |
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