West Suffolk Hospital 'sorry' after Thurston postmaster died from heart attack following hip operation
A hospital has apologised after a postmaster died after the care he was given fell below "the high level of monitoring and treatment he should have received".
Barry Jefferson, 73, who ran the Post Office Stores in Thurston, was admitted to West Suffolk Hospital, Bury St Edmunds, on August 17 last year after falling at home and fracturing his right hip.
After 'relatively straightforward' surgery, three days later, Suffolk Coroner's Court heard this week, he was 'recovering well'.
But on August 27, the postmaster was placed in a side room following a positive MRSA test - the bug which causes sepsis - and had become unwell with 'nausea and vomiting'.
During August Bank Holiday weekend, he told nurses he felt bloated and had a swollen abdomen. The nursing team consulted doctors on call, who prescribed medication.
Over the course of the weekend, Mr Jefferson became increasingly unwell, the inquest heard on Monday.
But despite repeated escalation from the nursing staff, he was only reviewed by 'very junior doctors', and five days passed without review or input from senior clinicians.
In addition, the inquest heard, following clinical reviews, documentation was often poor or missing.
On September 1, a review by the advanced nurse practitioner pointed to a possible infection, the source of which was "unknown".
Antibiotics and fluids were administered intravenously but Mr Jefferson became more unwell overnight and began vomiting.
Following an X-ray and referral to the surgical team, he suffered further deterioration and an emergency call was activated.
Irreversible organ failure was suspected when he did not respond to resuscitation treatment by the emergency team.
He died of a heart attack a short time later.
Following his death a serious incident report was completed by West Suffolk NHS Foundation Trust, which identified a number of 'care and service delivery' issues.
A West Suffolk NHS Foundation Trust spokesperson, said: "Mr Jefferson came to us following a fall at home and while his initial treatment appeared successful we are very sorry that his subsequent care fell below the high level of monitoring and treatment that he should have received.
"We offer our sincere apologies and condolences to his family and friends.
We have already reviewed and changed our procedures to ensure that our patient handovers are more comprehensive and inclusive.
"In addition, we have reviewed and improved our escalation processes, and will carefully consider any further issues raised during the inquest."
Craig Knightley, a solicitor from Tees Law acting for Mr Jefferson's widow Sarah, said: “The report highlighted a series of delays in recognising deterioration in Barry’s condition during that fateful Bank Holiday weekend and tardiness in seeking senior reviews and investigations.
"Establishing why things went so badly awry has not been helped by a repeated lack of documentation by the junior doctors who reviewed Barry, it being recorded during the inquest that the documentation fell far below what would have been expected from a junior doctor.
Sarah Jefferson is grateful to the Coroner for the thorough investigation into Barry’s death.
"Hopefully, following the hospital trust’s findings and the measures that have been implemented since Barry’s death, the incidence of failures to escalate the response to clearly deteriorating patients will have been greatly reduced.”