A patient who underwent weight-loss surgery died after a series of “failures” by the hospital to properly address complications during the junior doctors’ strike.
Susan Evans, 55, was readmitted to Queen Alexandra Hospital in Portsmouth just two days after having gastric bypass surgery in July 2023. She reported stomach pain on July 13, the first day of the strike, but was not seen by a senior doctor or a specialist bariatric nurse, as required by hospital policy. Ms. Evans was sent home, but her condition worsened, and she was readmitted days later in a critically ill state. She died on August 12, 2023.
An inquest into her death revealed several “failures” by Portsmouth Hospital NHS Trust, which contributed significantly to her death. Coroner Sally Olsen explained that Ms. Evans had undergone Roux-en-Y gastric bypass surgery on July 11. The surgery, designed to aid weight loss by reducing stomach size and rerouting the small intestine, was initially successful. However, Ms. Evans developed stomach pain on July 13, a complication that could have been a sign of an anastomotic leak, a known risk of the surgery.
On that day, the hospital had only one full-time bariatric nurse, who was not on duty. Furthermore, Ms. Evans was not seen by a senior doctor or a member of the bariatric team, despite guidelines stating that a senior doctor should be consulted if a patient reports abdominal pain shortly after surgery. The coroner noted that hospital staff who were not part of the bariatric team were unlikely to understand the seriousness of the situation.
Ms. Evans was discharged despite ongoing pain, but two days later, she was readmitted in critical condition, suffering from sepsis. She underwent corrective surgery on July 15, followed by another operation 10 days later. Despite receiving medical care after her readmission, her health continued to decline, leading to her death in August.
The coroner stated that if Ms. Evans had been seen by a member of the bariatric team on July 13, her condition may have been treated earlier, potentially saving her life. “The failures identified contributed more than minimally to her death,” Ms. Olsen concluded.
In a report on preventing future deaths, the coroner raised concerns about the hospital’s failure to follow its own policies. According to the hospital’s post-operation guidelines, a bariatric specialist or senior doctor should have reviewed Ms. Evans on July 13, especially after she reported pain. “The failure to follow policy contributed more than minimally to Ms. Evans’ death and is therefore a matter of concern,” the coroner said.
Portsmouth Hospital NHS Trust has until February 7, 2025, to respond to the coroner’s findings.
