Mr George was initially admitted to the Royal Cornwall Hospital, via Ambulance, on 9th August 2015. He was diagnosed with mild, acute, pancreatitis. On 16th August 2016, he was, unbeknown to his treating Consultant, discharged in error by a junior doctor.
A plan was made for him to be reviewed by a Consultant Upper-Gastrointestinal Surgeon within six weeks, with a view to arranging for his gallbladder to be removed. The Trust arranged for an appointment for 20th November 2015, almost 14 weeks later. No one at the Hospital noticed the error and Mr George had to re-arranged the appointment for himself, to 06th October 2015 (seven weeks after his discharge).
At the appointment, the Consultant booked Mr George for an urgent, laparoscopic, cholecystectomy (gallbladder removal via keyhole surgery). The Consultant tried to book Mr George’s surgery, but no one answered the ‘phone and the Hospital did not have an answerphone facility for the Consultant to leave a message. No one followed this up. During this appointment, blood tests were undertaken, but the Hospital did not undertake all that were needed, nor did they undertake the basic ECG (heart tracing) that was needed.
On 19th November 2015, six weeks after his Consultant had referred him for urgent surgery, Mr George had his pre-operative assessment carried out over the telephone, by a nurse from the Hospital.
Because the Hospital had not carried out all the pre-operative blood and cardiac tests that were needed, a referral had to be made for Mr George’s GP Surgery, The Park Medical Centre, St. Austell, to do this for them. The Hospital did not mark the test requests to the GP as urgent. On 25 November 2015, the surgery did some of the tests, but not all. This was not communicated to the GP Surgery until almost a month later, on 22nd December 2015.
Very sadly, Mr George suffered a more serious bout of pancreatitis, caused by the same gallstones, on 3rd January 2016. He was rushed to Hospital by Ambulance, but died four days later. At the time of his death, Mr George had still not had all his routine pre-operative tests undertaken, nor had he been given a date for the surgery the Hospital Trust said he needed urgently 4 ½ months earlier.
Mr George’s death was needless and entirely avoidable and has utterly devastated his family.
It is hoped that the Inquest will explore the following issues:
- Why Mr George did not have his surgery within either seven days, or six weeks, as mandated by National Guidelines.
- What opportunities were lost by the Hospital Trust in identifying the need for urgent surgery, including delayed Consultant follow-up, an inability to book a date for surgery, lack of face-to-face pre-operative assessment, nurse reviews, blood and ECG tests.
- Whether the Hospital Trust’s failings amount to gross negligence and a possible finding by the Coroner of Unlawful Killing.
- Whether the serious and systemic nature of the Hospital Trust’s failings were such that they unlawfully deprived Mr George of his right to life.
- Whether the subsequent actions taken by the Hospital Trust are sufficient to prevent future deaths.
Her Majesty’s Senior Coroner for Cornwall and Isles of Scilly, Dr Emma Carlyon, has declared that the Inquest will also investigate whether the Hospital Trust has breached their duties under Article 2 of the Human Rights Act (the Right to Life), by failing to implement the National Guidelines and best practice to ensure that the timelines for gall stone procedures were achieved. In particular, the inquest will test whether any breaches of General or Operational Obligations on the part of the Hospital Trust led to Mr George’s death.
Mr George’s son, Kevin George, said:
“My Dad was always kind, helpful, generous and loving man. He was a proud and loving Dad and Granddad and a devoted husband to my Mum, until her death in 2009. Our hope as a family, is that the Inquest will fully explore what went wrong with Dad’s care and ensure that there are changes so that this never happens to another family. This Inquest is happening because of the Hospital Trust’s failures. It is not something that we have asked for, yet it must take place to provide answers as to what went wrong with Dad’s care and how things can be changed to avoid future deaths.
Whilst is the Hospital Trust are able to use taxpayers’ money to instruct lawyers to represent them and their staff at the Inquest, we, as a family, are unable to do so. How is this fair?”
Mary Smith, the family’s lawyer, said:
“The Royal Cornwall Hospitals Trust has admitted liability for Mr George’s death, acknowledging that it arose as a direct consequence of delays and gaps in the Trust’s systems and processes. Mr George suffered a painful, unnecessary, death from a common and treatable condition. His family deserve to know the full extent of the Trust’s failings.”
S J Edney Solicitors have been working with Mr George’s family, in conjunction with barrister, Sophie Holme, of Guildhall Chambers, since July 2016. The inquest will be held in Truro on 14 & 15 June 2017, where the family will be represented by Sophie Holme.