Clinical Negligence Lawyer Demands Urgent Review After Surgeon Punctures Bowel Three Times During Same Operation
09/06/2011
A clinical negligence lawyer has called upon an NHS Trust to undertake a full review after an inquest heard how a patient died when his bowel was perforated THREE times during the same operation.
Brian Gronow, 72, suffered multi organ failure on 19th April 2011, just four days after a keyhole gallbladder operation at Walsgrave Hospital in Coventry, after the medical staff returned him to the ward where the life threatening damage to his bowel went undetected for two days.
Despite being rushed back to theatre with severe blood poisoning, Mr Gronow tragically died, leaving his family desperate for the answers as to why the fatal errors had not been identified sooner.
Today, Louise Hunt, Deputy HM Coroner for Coventry and Warwickshire recorded a narrative verdict as an inquest heard that Mr Gronow’s bowel had been perforated three times, but that the holes were missed by two experienced surgeons at the time of surgery.
The verdict has prompted clinical negligence lawyer Lindsay Gibb from Irwin Mitchell to call for an urgent hospital review to establish why two different surgeons failed to acknowledge the danger that Mr Gronow was in.
Mr Gronow, a former painter and decorator who was married with one daughter and three grandchildren, had initially been treated at Coventry's Walsgrave on 30th March 2011 to have gallstones removed. This procedure had been successful but he was informed by doctors that he would need to have his gallbladder removed at a later stage to prevent the condition from reoccurring. Although he was told that there was no urgency for this procedure, he received a letter marked ‘urgent’ just days later to say that surgery to remove his gallbladder had been scheduled for 15th April.
The keyhole procedure was performed by Specialist Registrar, James McDaid and Jeff Gilmour, Senior Clinical Fellow. The inquest heard that, shortly after surgery had begun, Mr Gilmour had received an emergency call to attend the ward. Mr McDaid started the procedure without his supervision and, during this time, he experienced difficulty as he tried to insert the instruments to carry out the keyhole procedure.
Mr McDaid later asked theatre staff to page Mr Gilmour, who returned to theatre. At the fourth attempt, an alternative entry site was successfully located. However, by then Mr Gronow’s bowel had been perforated three times. It is not clear whether all three holes were created by Mr McDaid during the initial attempts or whether the third hole may have been made by Mr Gilmour, but none of the holes were detected by either surgeon at the time of surgery. Mr Gronow was then returned to the ward.
When staff at the hospital told Mr Gronow’s wife, Joan, that he had been transferred to critical care and had only a 5% chance of survival, she collapsed from shock at home and she was rushed to Walsgrave Hospital with a broken hip. After undergoing emergency surgery, she came out of theatre to be given the devastating news that her husband had died.
The inquest heard from Consultant, Mr Saboor Khan who, whilst not directly involved in Mr Gronow’s surgery, had been ultimately responsible for the care that his surgical team provided. He offered an unreserved apology to the family.
Ms Gibb, a medical law specialist with Irwin Mitchell, who represents the family and is taking separate civil action on their behalf, explained: “This is a truly shocking and appalling case. Brian Gronow’s care at Walsgrave Hospital raises a number of urgent questions. Although a bowel perforation during keyhole surgery can be a known complication, to make not two, but three such errors during the same operation, raises serious concerns.
“The fact that Mr Gronow was not then put on close observation following the operation is of further concern particularly when no urgent action was taken when he reported severe abdominal pain and his condition deteriorated. There appears to have been a ‘wait and see’ attitude to Brian’s post operative care and crucial opportunities to treat his punctured bowel appear to have been missed.
“Furthermore, the family is very concerned that Brian’s elective surgery appeared to have been rushed through. Following his death, the hospital informed the family that, due to an influx of cancer patients, the department had only a two week slot for elective procedures and had decided to try to get as many routine operations done as possible. Understandably, the family is anxious to know if this rush might have led to Brian receiving substandard care.
“The consultant in charge of Brian’s care has apologised unreservedly to the family and although they have taken some comfort from this they are anxious for the Trust as a whole to undertake a full scale review of what happened to ensure that lessons have been learned.”
Mr Gronow’s widow, Joan, commented: “The entire family has been devastated by what has happened. Brian was the centre of our family and I cannot come to terms with the way he died. I have lost a husband and my daughter, Wendy and grandchildren, Keith, Joanne and Leanne, have lost a much loved father and granddad.
“Brian and I had been married 50 years and as part of our celebrations we had planned to go away to Ibiza. Instead, I buried Brian the day before we were due to go on holiday.
“I’m so angry about the care Brian received. He put his trust in those surgeons and they let him down very badly. I just hope the Trust will now look at what went wrong and take action to make sure another tragedy like this doesn’t happen to another family.”
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