Weight-loss surgery patient died after hospital ‘failures’ during junior doctors’ strike

2 January 2025, 16:22

A weight-loss surgery patient has died due to a series of "failures" by a hospital to treat complications that arose from a procedure during a junior doctors' strike.

55-year-old Susan Evans returned to Queen Alexandra Hospital in Portsmouth with tummy pain two days after having a gastric banded fitted in July 2023.

It was the first day of industrial action and the coroner stated there was no specific weight-loss nurse on duty.

Ms Evans was not attended to by a senior doctor and was discharged, only to return to the hospital "extremely unwell".

Her condition deteriorated and she died in August 2023.

An inquest into her death heard of “failures” by Portsmouth Hospital NHS Trust that “contributed more than minimally to her death”.

Read More: New Orleans attack ‘could be linked’ to Cybertruck explosion - as police probe military connection

Read More: Man, 25, dies after car hits pedestrians on Christmas Day in London's West End

Sally Olsen, assistant coroner of Hampshire, Portsmouth and Southampton, recalled that Ms Evans had elective Roux-en-Y gastric bypass surgery on July 11 2023.

The procedure helps with weight loss as it reduces the size of the stomach and re-routes the small intestine.

An inquest heard the surgery “went to plan” and measures were taken to avoid the possibility of an anastomotic leak, which is a recognised complication of gastric bypass surgery.

At first Ms Evans "recovered well" but experienced stomach pain in the early hours of July 13.

Ms Olsen added: “Unrelated to this, the hospital only had the equivalent of one full-time specialist bariatric nurse, who was not on duty.

"Contrary to Queen Alexandra Hospital’s written policy for gastric bypass patients, Ms Evans was not seen by a member of the specialist bariatric team [on that day] and was not seen by a senior doctor after reporting pain in order to rule out the possibility of an anastomotic leak.”

Apparently the night team, who administered pain relief, were "unaware" of the latter requirement.

Before being discharged Ms Evans was also not seen by a member of the bariatric team, which is a group of medical professionals who work together to treat patients with obesity.

When she left Portsmouth hospital she was "in a degree of pain".

When she returned, she was “extremely unwell” with sepsis and had to undergo remedial surgery on July 15.

She then had an additional operation ten days later.

The coroner said: “Despite appropriate medical care following her re-admission, her condition deteriorated, and she died at Queen Alexandra Hospital on August 12 2023.

"It is likely that, if she had been seen by a member of the bariatric team on July 13 2023, she would have been kept in hospital and would have been operated upon sooner.

"The failures identified contributed more than minimally to her death.”

In a prevention of future deaths report, addressed to the Portsmouth Hospital NHS Trust, Ms Olsen said her inquiries revealed several “matters giving rise to concern”.

The coroner said that under Queen Alexandra’s post-operation care guidance, a bariatric specialist nurse, consultant or registrar was required to carry out a daily review on patient of weight-loss surgery.

A senior doctor was also meant to check a patient to see if they suffered from abdominal pain within two hours of going to hospital.

The coroner said: “Neither the written nor informal policy set out above were followed in Ms Evans’ case.

"She was not reviewed by a member of the specialist bariatric team at any point on day two after surgery, and the pain she experienced from the early hours of July 13 was not escalated to a senior doctor at all.“