Failings led to weight loss surgery death - coroner

Susan Evans, 55, died from abdominal sepsis at Queen Alexandra Hospital

Failings at a hospital led to the death of a woman who had undergone weight loss surgery, a coroner has found.

Susan Evans, 55, died from abdominal sepsis at Queen Alexandra Hospital in Portsmouth on 12 August 2023.

She underwent elective gastric bypass surgery on 11 July and, despite suffering abdominal pain, she was discharged two days later without being seen by the specialist bariatric team or a senior doctor.

Portsmouth University Hospitals NHS Trust said it was cooperating with the coroner and would respond to the issues raised in the report.

A prevention of future deaths report, by coroner Sally Olsen, concluded that the failures to check on Ms Evans "contributed more than minimally to her death".

The Queen Alexandra Hospital's written policy for gastric bypass patients states there should be daily reviews by a bariatric specialist nurse, consultant or registrar.

It also makes clear that a patient should be seen within two hours by a senior doctor if they have increased abdominal pain.

The coroner's report found these policies were not followed.

It highlighted that the hospital only had the equivalent of one full-time specialist bariatric nurse, who was not on duty at the time.

It also noted that 13 July was the first day of a junior doctors' strike.

'Extremely unwell'

Ms Olsen said Ms Evans was still in a degree of pain when she left hospital.

"She was re-admitted to hospital on 15 July 2023. By this point she was extremely unwell with abdominal sepsis from an anastomotic leak," Ms Olsen said.

She added that despite "appropriate medical care following her re-admission" Ms Evans' condition deteriorated.

The coroner believed that if the correct procedures had been followed after the initial surgery then it is likely that Ms Evans would have been kept in hospital and could have been treated sooner.

"There is a risk that future deaths could occur unless action is taken," Ms Olsen said.

Dr John Knighton, chief medical officer at Portsmouth Hospitals University NHS Trust, said: "I am very sorry for the care we provided to Susan and would like to send my deepest condolences to her family.

"We continue to fully cooperate with the Coroner and will be responding to the issues raised during Susan's inquest.

"A full internal investigation has also taken place and we are taking action to improve our care especially the communications between clinical teams and our patients when they leave hospital."