A lack of ‘continuity of care’ contributed to the death of a former scrapyard owner who passed away days after a routine operation to remove a hernia at Northampton General Hospital.
Sarah Elliott, 51, of Bedford Road, Brafield on the Green, had a history of hernia problems following a hysterectomy in 2006 and took the decision to have one removed from her abdominal wall on December 17, 2012.
An inquest into her death this week found that the operation, carried out by surgeon Doctor Robert Hicks, appeared to go smoothly at first.
But over the next few days she deteriorated rapidly and four days later, she was diagnosed with suffering from sepsis.
On Saturday, December 22, a further operation was carried out to find the cause of the problems and a ‘pinhole’ puncture was found on her large bowel. It was repaired, but she died later on that day.
A review into her death carried out by the hospital found the severity of her condition was not communicated well enough between the various doctors that cared for her over those days. Though she did not show obvious signs of sepsis, her heart rate had increased rapidly, and her blood pressure dropped, which should have been her placed as a higher risk patient.
Speaking at the inquest on Friday consultant surgeon John Evans, who led the investigation, said: “She had been seen by a succession of general doctors over the course of Friday who didn’t know her.
“There was a lack of continuity of care there, with different people seeing her at different stage - and she did deteriorate over the course of the day.”
The inquest heard that several other factors could have improved Ms Elliott’s chances of survival.
High patient volumes on the Saturday meant an intensive care unit bed was not available after her second operation.
Doctors instead removed her breathing pump and treated her in a recovery room. Mr Evans said ‘in hindsight’ she would have stood a better chance of survival if she had been moved to intensive care.
The on-call anaesthetist for that day was also unavailable as his mobile phone had run out of battery, though Mr Evans said a replacement was promptly made available.
Deputy coroner for Northamptonshire Rodney Haig, delivering narrative verdict into the death, said after hearing all the evidence, he could not determine how the fatal perforation to the bowel was caused.
Speaking at the inquest, Ms Elliott’s sister, Janice Elliott, said: “It seems to me that this is an accumulation of lots of different things that went wrong.”
Mrs Elliott worked at Anglian Water and later ran a scrapyard in Northampton with her partner in recent years.
Describing her, sister Janice, of Cherry Court, Northampton, said: “She loved gardening and making fruit and jams from her garden. She was a hard-working, approachable, caring person, who kept her private life to herself.”