A coroner has determined that failures at a hospital led to the death of a woman who underwent weight loss surgery. Susan Evans, 55, passed away from abdominal sepsis at Queen Alexandra Hospital in Portsmouth on 12 August 2023.
Evans had surgery for a gastric bypass on 11 July. Despite experiencing abdominal pain, she was discharged just two days later. At the time of her discharge, she had not been seen by the specialist bariatric team or a senior doctor.
Portsmouth University Hospitals NHS Trust has acknowledged the report and said it is cooperating with the coroner’s investigation. The trust also stated it would address the issues raised in the report.
Coroner’s Report Highlights Lapses in Care
The coroner, Sally Olsen, concluded that the hospital’s failures in Evans’ care “contributed more than minimally to her death.” The hospital’s written policy for gastric bypass patients requires daily check-ups by a bariatric specialist, consultant, or registrar. It also mandates that a senior doctor should see any patient with increased abdominal pain within two hours.
The coroner’s report found that these protocols were not followed in Evans’ case. At the time, the hospital had only one full-time bariatric nurse, who was not on duty. Additionally, the report noted that Evans was discharged on 13 July, the first day of a junior doctors’ strike.
Ms. Evans’ Condition Deteriorates
Olsen explained that Evans was still in pain when she left the hospital. She was readmitted on 15 July 2023, by which time her condition had worsened significantly, and she was diagnosed with abdominal sepsis from an anastomotic leak.
Although Evans received appropriate medical care upon her readmission, her condition continued to deteriorate. The coroner stated that had the proper procedures been followed after her initial surgery, it was likely that Evans would have been kept in the hospital longer and treated sooner.
“There is a risk that future deaths could occur unless action is taken,” Olsen warned.
Trust Responds to the Findings
Dr. John Knighton, Chief Medical Officer at Portsmouth Hospitals University NHS Trust, expressed his sorrow over the incident. “I am very sorry for the care we provided to Susan and would like to send my deepest condolences to her family,” he said.
The Trust confirmed it is fully cooperating with the Coroner and will address the issues raised during the inquest. A full internal investigation has already been conducted, and steps are being taken to improve patient care, especially concerning communication between clinical teams and patients upon discharge.
