Coroner Calls for Safety Review after Scunthorpe and Grimsby Hospital Deaths

The latest inquest, held at Cleethorpes Town Hall, heard that Robert Connon, 81, of Western Outway, Grimsby, had undergone the surgery at Grimsby's privately-run St Hugh's Hospital. He was later transferred to Grimsby's Diana, Princess Of Wales Hospital when his blood pressure dropped.


A review of patient safety has been requested by the coroner for northern Lincolnshire who has dealt with three inquests involving people who underwent hip operations.

The surgery was carried out on July 28 by Consultant orthopaedic surgeon Tajesh Bagga, who had successfully completed more than 2,000 hip replacements in his 20 year career both with the Northern Lincolnshire and Goole Hospitals NHS Trust and in private practice.

Hospital consultants told coroner Paul Kelly that death in patients having replacement hips was extremely rare.

But he told them he had presided over inquests into the deaths of two other patients in the past seven months:

• Leonard Ireland, 91, of Ward Street, Cleethorpes, who died after surgeons at Grimsby's Diana, Princess of Wales Hospital tried to repair a broken hip, and he suffered an infected wound.

• Scunthorpe man Maurice Cowling, who died of heart failure after a drill broke and punctured one of his arteries during a hip operation at Scunthorpe General Hospital.

Mr Kelly said: "I would be failing in my duty if I did not invite the chief executive of the hospital Trust to undertake a review into patient safety in relation to these procedures to include the appropriateness of and the provisions that are in place to deal with post-operative complications."

The inquest heard a 25mm screw was protruding by about 7mm, rupturing pelvic blood vessels.

Pathologist Dr Martin Peters said he discovered it when he carried out the post mortem examination.

He said the cause of death was pelvic haemorrhage due to complication in the hip replacement operation.

He said the retired businessman suffered osteoarthritis, high blood pressure and had chronic pulmonary obstructive disease.

Dr Peters said: "He could have dropped dead at any time. In a younger fitter person it might have been survivable, but this was not a young fit man."

Mr Bagga, an NHS consultant, said he often carried out private operations at St Hugh's Hospital.

He said the operation had gone according to procedure and he had seen no bleeding.

The consultant said he had never encountered the problem of a protruding screw before.

He said: "It is extremely rare. I was very upset about the whole thing."

Consultant anaesthetist, Roderick Bramwell told how he decided the patient should be transferred after his blood pressure dropped significantly. He later suffered cardiac arrest but was resuscitated. He died on July 29.

The barrister representing Mr Connon's family, Andrew Scott, asked if he felt St Hugh's Hospital was the most appropriate place for an operation for an 81-year-old with high risk factors, away from an NHS hospital, Dr Bramwell said: "Hindsight is a wonderful thing. For people aged 65 years to 98 years, they all have co-morbidity factors."

He added: "There are more knee and hip operations carried out at St Hugh's Hospital in the choose and book system than at Diana, Princess of Wales Hospital."

He said the Grimsby hospital did not have the capacity to do all such operations.

He said if the private sector "cherry picked" only those patients that it wanted because they were fitter the £5,500 cost to the NHS would go up.

Mr Scott said: "If lessons can be learned from this that will be a comfort to the family."

He said there was no criticism of doctors or the hospital from relatives.

Wendy Booth, NLAG's executive director of performance assurance, said: "We have already investigated the circumstances surrounding Mr Connon's death.

"The Trust will await the correspondence from the coroner and consider the need for any further Trust action. I would like to take this opportunity to express my condolences to the family for their loss."

Donna Read, director of St Hugh's Hospital said: "St Hugh's Hospital and all its staff offer their condolences to Mr Connon's family and friends following his death.

"As the Coroner found, this was the result of a known complication following hip replacement surgery.

"St Hugh's Hospital undertakes around 500 joint replacements annually. We are absolutely focused on providing the highest quality of patient safety and care at all times."

Mr Kelly concluded that Mr Connon died as a result of complications arising from hip surgery.

Mr Connon's son Nigel told how his father was multi-talented and "turned his hand to anything."

He was a one-time taxi driver, watchmaker, jeweller and could repair most household items.

He said his father was a keen golfer and enjoyed bowls.

He was married for more than 60 years and had three children.

He added: "He was a lovely man and a great friend to many. His death has left a huge void in the family and he is very much missed by all his family and friends."


Source: Scunthorpe Telegraph



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