Coroner warns of private hospital risk after patient dies following care failures
A coroner has issued a warning over safety at private hospitals after opportunities to save a patient were missed.
Simon Healey died in 2017 from complications following bowel surgery carried out at the Berkshire Independent Hospital in Reading, part of Ramsey Health Care.
Now senior coroner for Berkshire, Heidi Connor, has said lessons must be learned after failures in Mr Healey’s care meant his deterioration and eventual sepsis were not escalated or treated adequately until it was too late.
The 60-year-old businessman and father of five underwent his operation on August 1 following referral by his NHS doctor, who also practised in the private hospital.
The operation was to remove a section of Mr Healey’s colon following a diagnosis of bowel cancer.
Six days after the operation, Mr Healey, from Finchampstead in Berkshire, was diagnosed with a leaking bowel leading to sepsis.
Despite further surgery to repair the leak, his condition deteriorated and he died from multiple organ failure caused by septic shock on August 10.
In her report, the coroner said: “Simon Healey suffered a recognised complication of bowel surgery.
“Opportunities for earlier detection of an anastomotic leak and subsequent sepsis were missed.
“If this had been detected at any point up to the 6th August 2017, it is likely that he would have survived. He died on the 10th August 2017.”
During the inquest into his death, independent consultant colorectal surgeon, Professor John Scholefield, said Mr Healey, could have survived if his condition was picked up earlier.
In her report, Ms Connor said private hospitals must review their use of the National Early Warning Score (News), which is used to detect clinical deterioration in adult patients.
“This relates not only to awareness of the policy and sepsis training generally, but also consideration of the arrangements for escalating care where a patient becomes critically unwell,” she said.
“Most private hospitals do not have a full critical care capacity (in terms of facilities and staff) and rely instead on a consultant’s availability to attend and review the position.”
She said the escalation policy at Ramsay Healthcare at the time of the incident “clearly anticipates initial review by a consultant, outside the hospital, who may well not be available to attend on an emergency basis”.
She also issued a warning on the expertise of staff in the private sector, saying “nursing staff in this context may well never have cared for a patient after this operation, and not be familiar with the signs and symptoms to be aware of and, in particular, to alert clinical teams to signs which point towards leak and/or sepsis”.
She said the case raised questions over “whether private hospitals should be carrying out procedures like this without specialised nurses and without facilities to escalate care without delay”.
She also condemned the initial inquiry by Berkshire Independent Hospital into what happened to Mr Healey as “inadequate”.
Mr Healey’s wife, Alison, told the Health Service Journal (HSJ): “I am absolutely convinced that Simon was abandoned.
“There was no open and honest communication with me from the staff, no-one told me he had sepsis.
“I was completely in the dark. Simon placed his entire trust in them. He was a very thorough man and had an attention to detail and, at a time in his life when he needed the same, they utterly failed him.”
She said her husband did not want to wait for surgery on the NHS because he was worried about his cancer, and agreed to be referred privately.
She added: “If Simon had been treated at the (NHS) Royal Berkshire he would be here today. Patients are in the dark when they go into the private sector. It should be operating at the same standards as the NHS.”
Ramsay Health Care apologised to Mr Healey’s family and said in a statement: “An internal investigation has been completed at Berkshire Independent Hospital to ensure that all lessons have been learnt and the practising privileges of the consultant have been terminated.
“Ramsay Health Care rolled out our global Speaking Up For Safety Programme in 2018.
“Delivering safe, high-quality care remains at the core of what Ramsay stands for as an organisation and we remain committed to providing the highest standards of care for all our patients.”
The Independent Healthcare Providers Network (IHPN) said in a statement that News policies had been “implemented as standard across the independent healthcare sector since 2012”.
It added: “Independent hospitals, like NHS providers, undertake robust pre-admission processes to establish that they are an environment in which a patient can be safely treated.
“Unanticipated deterioration in the condition of patients is a factor in all healthcare settings and so the right response is to have plans in place to deal with it when it occurs.”
Mr Healey was a director of the Mace Group.
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