Hospital apologizes for ‘failures in care’ that contributed to teacher’s death

A hospital has apologized to the heartbroken family of a former teacher who died following ‘gross failures in care’.

Susan Moore sadly passed away at Royal Stoke University Hospital after undergoing hip replacement surgery.

Following an investigation into the 68-year-old’s death, a coroner found that shortcomings in her care amounting to neglect contributed to the tragedy.

An inquest heard nurses looking after Mrs Moore failed to carry out necessary observations and there was a delay in spotting a post-operative complication that ultimately caused fatal cardiac arrest, according to Stoke-on-Trent Live.

An “unreserved apology was issued to the loved ones of the patient by University Hospitals of North Midlands NHS Trust (UHNM), which runs the Royal Stoke and County hospitals, who added that ‘a number of actions’ have been taken to improve procedures and protocols.

Mrs Moore was admitted to the Royal Stoke on May 27 last year for an elective hip replacement, due to osteoarthritis.

She suffered from a number of other health problems and had previously undergone major abdominal surgery, which put her at high risk of developing complications following her hip replacement.

Because of this, two other hospitals had declined to carry out her surgery, insisting it needed to be done at the Royal Stoke because it was better equipped to care for high-risk patients.

The inquest heard the operation went as planned, but Mrs Moore became unwell in the days that followed.

Her husband, Adrian Moore, said she was ‘very unwell’ and vomiting repeatedly when he visited her on May 30 and 31. However, no mention of vomiting was made in the nursing notes until May 31.

By the night of May 31, there were concerns that Mrs Moore may have a gastro-intestinal bleed and arrangements were made for her to be x-rayed.

However, before this could be done, she suffered a cardiac arrest following a severe episode of vomiting, which caused her to aspirate. Attempts were made to resuscitate her, but she was pronounced dead at 1.17am on June 1.

A post-mortem examination revealed Mrs Moore, of Penkridge, had developed a paralytic ileus – a temporary paralysis of the muscle contractions that move food through the intestine.

She died from a cardiac arrest caused by aspiration, linked to the hip surgery and the ileus. Other health problems, including hypertension, kidney disease and Crohn’s disease, also contributed.

The inquest heard Mrs Moore had an increased risk of developing an ileus due to her previous abdominal surgery, and repeated vomiting was a key symptom of the condition.

Philip Shaylor, the surgeon who performed Mrs Moore’s hip surgery, said it should have been diagnosed sooner, and her life could have been saved if it had.

Now retired, Mr Shaylor told the inquest: “She was suffering from abdominal problems that weren’t appropriately investigated.

“I feel if appropriate management had been put in place to deal with the ileus, we could have prevented the aspiration and Mrs Moore would have been alive today.

“In my opinion, the cause of death was the failure to recognize the ileus and deal with it in an appropriate nature in a high-risk patient.”

An internal investigation carried out following Mrs Moore’s death by ward manager Sally Keay found observations were not completed at the required frequency over the weekend following the operation.

Ms Keay said a number of lessons had been learned from Mrs Moore’s case and the hospital trust had put an action plan in place to address the issues raised in the report.

Having heard the evidence, North Staffordshire assistant coroner Sarah Murphy ruled there had been a gross failure to provide basic medical care, which amounted to neglect.

She formally concluded that Mrs Moore died due to a complication of necessary surgery against a background of natural disease and contributed to neglect.

Ms Murphy said: “I heard alarming evidence that, despite clinicians being aware of Mrs Moore’s deterioration on May 31, three sets of observations were missed. I consider this, in itself, to be a very serious failing given Mrs Moore’s co-morbidities and her deteriorating condition.

“When the failings identified in the report are looked at in the round, there were gross failures in care and a delay in diagnosing the paralytic ileus. On the balance of probabilities, Mrs Moore’s death would have been prevented if there was an earlier diagnosis and treatment given.”

Following the hearing, Ann-Marie Riley, UHNM’s chief nurse, said: “We fully accept the coroner’s findings and offer an unreserved apology as there were aspects of Susan Moore’s care which were not managed as well as they should have been.

“We take all issues raised very seriously and have taken a number of actions to ensure our staff learn from her sad death, such as improvements to the process and staffing for daily review post-operations.”

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George Holan

George Holan is chief editor at Plainsmen Post and has articles published in many notable publications in the last decade.

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