A coroner has said a 67-year-old man would have survived if it had not been for “failures” in the care he received from Northampton General Hospital and his GP.
Stuart Gordon, known as ‘Tapper’, of Queen’s Road, Northampton, went into Northampton General Hospital on October 8 last year to have an operation to remove a hernia from his groin.
As a result of the surgery, Mr Gordon suffered a tear in his small bowel and over the next two days he suffered considerable pain and discomfort.
The inquest heard Mr Gordon’s wife had phoned the hospital later the same day he had been discharged and told a nurse he was suffering some pain and was feeling sick.
Despite being told he could come back to the ward in the event of any complications from his surgery, a nurse told Mr Gordon’s wife he should go to the out-of-hours service.
The next day Mr Gordon was taken to see his GP Dr Mahmood Kausar, who works at King Edward Road Surgery in Northampton.
Despite a ‘high suspicion’ the pain may be related to the surgery, Dr Kausar decided to send Mr Kausar home with some morphine rather than refer him back to accident and emergency.
Mr Gordon, a father of five and a grandfather of 10, died the next day after he was rushed into hospital and his condition deteriorated.
An inquest at County Hall heard today that “windows of opportunity were lost” to save him after he was discharged from hospital.
County Coroner Anne Pember said it was “totally unacceptable” that Mr Gordon’s wife Jennie was told to take her husband to the out-of-hours service after she phoned up the hospital because he was in pain later the same day after his operation.
Ms Pember said: “An opportunity was lost when Mr Gordon’s wife was advised by a nurse to contact the out-of-hours service. On this occasion the hospital failed Mr Gordon.
“A further failure was when he went to see his GP the following day and he was prescribed morphine rather than sent back to accident and emergency.”
The coroner said, had Mr Gordon been taken back to hospital when his wife phoned up or when he saw the GP, it was “likely” that he would have survived.
Mr Gordon’s wife Jennie said her family had been “devastated” by his death and has called for greater controls in hospital so that other patients don’t suffer the same fate.
Mrs Gordon said: “So many people, his children, his grandchildren and his family, revolved around him. This shouldn’t have happened to him.
“This was a routine operation and Stuart should be with us now. This shouldn’t have happened and the hospital should make sure that procedures are tightened up so this doesn’t happen again to another family.”
Matthew Olner, of Nelsons Solicitors who acted for the Gordon family at the inquest, said: “In her verdict the coroner found that the hospital and GP had failed to arrange Mr Gordon’s re-admission to hospital and that opportunities to successfully treat the perforation were missed.
“The family want the hospital to learn from this mistake. This man’s operation went wrong and this wasn’t picked up until it was too late.”
A spokesman for Northampton General Hospital NHS Trust said a number of changes had been introduced as a result of the failings in the care given to Mr Gordon.
Dr Robert Hicks, consultant general surgeon at Northampton General Hospital who gave evidence to the inquest on Wednesday, said a number of changes had been made at the hospital as the result of Mr Gordon’s death including a new, clearer policy on the information given to patients about when they should come back to hospital.
Dr Hicks said there was now a ‘if in doubt return to theatre’ policy rather than the ‘watch and wait’ policy adopted by Dr Kausar.
He said the nurses had also been given a new colour coded chart of red, amber and green signals which made it clearer when a patient should be taken back to hospital.
A spokesman for Northampton General Hospital said: “We appreciate this has been a very difficult time for the family and would like to take this opportunity to apologise again for any failings in the care Mr Gordon received and offer his family our sincere condolences.
“We have undertaken our own internal investigation as well as bringing in an external expert to ensure we have identified every opportunity to learn from what happened.
“We hope the evidence given to the coroner regarding the changes made at the trust since this sad death provides reassurance that we have done everything we can to prevent any similar problems occurring in the future.