Coroner rules that critical delays led to death of Pontefract man
24/03/2010
A Coroner has concluded that the death of a man from a punctured artery at Dewsbury and District Hospital could have been avoided had he undergone emergency surgery more quickly.
Mr John Wynn, aged 50 from Pontefract, died following surgery for oesophageal cancer at Dewsbury and District Hospital on 21 May 2006. Following the initial operation which was carried out by Mr Abdul Basheer it was found that a chest drain had eroded his aorta.
The inquest into his death found that emergency surgery to save his life was not carried out quickly enough and a verdict of death by misadventure aggravated by negligence was given. The Coroner also raised concerns about the surgery performed, claiming that the “unorthodox” manner in which the operation was carried out prevented doctors from spotting the hole in his aorta. In his evidence Mr Basheer admitted that with hindsight he would not have placed the chest drain so close to the aorta.
Mr Wynn’s family is now urging the Yorkshire hospital to learn from its mistakes and ensure the necessary steps are taken to prevent further tragedies.
During the Coroner's investigations, worrying reports were given regarding the delays in obtaining blood. Mr Wynn had developed antibodies and the surgical team decided that cross-matched blood was needed. Dewsbury and District Hospital did not have the facilities to do this and the delay in transporting blood from a Leeds laboratory exacerbated the problem. Expert evidence at the inquest stated that O-negative blood could have been used but the surgical team had not fully appreciated the seriousness of the situation instead choosing to wait for the blood to arrive from Leeds. What should have been a 40 minute wait for blood turned into a 4½ hour delay.
Suzanne Munroe, a leading clinical negligence solicitor at Irwin Mitchell, said: "The inquest revealed a series of failings by hospital staff and if these had been recognised sooner Mr Wynn’s death could have been prevented. The family are very concerned with the treatment provided to Mr Wynn. Although the hospital has admitted liability for the death his family want to ensure that this does not happen again."
"There are issues over the delay in the appropriate treatment, the way emergency surgery was delivered and the unnecessary delay in obtaining suitable blood."
At the time of Mr Wynn’s death there were a number of other deaths at the Dewsbury and District Hospital all being examined by the Coroner. All of these were deaths than occurred under the care of Mr Abdul Basheer or his team. The inquest also heard that the General Medical Council were asked to review Mr Basheer's fitness to practice but did not take any action. He continues to work at Dewsbury and District General Hospital.
Mr Wynn's children, Aimee and Darren, said: "We are devastated to have lost our father and that our children have lost their grandfather. We are concerned that this tragedy could happen to another family and hope that the hospital will take action to make sure all staff are properly trained.
"These last few years have been an absolute nightmare for us. When my Dad died he was running a successful local pub but despite all the family pulling together we were unable to keep the pub going and were forced to sell it. We just want to try move on with our lives."
The inquest found that had treatment been successful, Mr Wynn would have survived the operation and gone on to have a reasonably good quality of life. Experts suggested a 60-65% chance of survival of 5 years. Medical negligence solicitors from Irwin Mitchell later secured a financial settlement for Mr Wynn’s family.
Miss Wynn said: "No amount of money can replace my father or make up for the suffering we have endured. We just want to make sure that no one has to suffer as we have."
Background
Mr Wynn was admitted to Dewsbury and District Hospital for surgery to remove cancerous tissue from his throat on 11 May 2006.
Following the operation, Mr Wynn complained of severe pain from his chest drains, with large quantities of blood coming out of the drains. Conservative treatment was continued but Mr Wynn became increasingly tired and breathless until eventually an emergency operation to open Mr Wynn's chest cavity was carried out.
The procedure revealed large amounts of internal bleeding and a 5mm hole in the aorta where a chest drain had been inserted. Mr Wynn had no heartbeat at this time and despite resuscitation attempts he passed away.
The post mortem later revealed that he died from a haemorrhage within the chest cavity and dramatic perforation of the aorta by the chest drain.
Clinical evidence suggested that the initial operation to remove the cancerous part of the oesophagus, and then to reconnect the remaining healthy parts, failed within 48 hours of the operation.
Suzanne Munroe said: "When Mr Wynn had a large bleed shortly after his operation immediate action should have been taken. The Coroner was told that an endoscopy at this point should have been mandatory and would have informed how they should operate to treat the bleed. It was found at the inquest that had Mr Wynn been operated on within 48 hours of his previous operation his life would have been saved. The doctors chose a wait and see approach. If attempts were made to find out where Mr Wynn was bleeding from the Coroner found that the surgeons would have found that the aorta was bleeding and the tear could have been repaired before Mr Wynn's second, and fatal, bleed later that day. What is particularly tragic is that Mr Wynn's condition deteriorated at around 5pm on the day he died, just at the time the cross matched blood arrived from Leeds"
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