Lita Serkes
PFD Report
All Responded
Ref: 2016-0458
All 1 response received
· Deadline: 9 Apr 2017
Coroner's Concerns (AI summary)
Multiple clinical failures occurred, including inaccurate medical records, delayed stroke diagnosis, critical delays in patient transfer to specialist care, and unreviewed crucial blood test results impacting treatment decisions.
View full coroner's concerns
1. The Whipps Cross medical notes record normal observations, most specifically that Mrs Serkes was “alert” at 9.50am on Saturday, 23 July 2016. However, by that time, her son had been at her bedside for nearly an hour and had himself realised that Mrs Serkes had suffered a stroke. He saw no nurse conducting any observations at this time.
Some five months on, no member of staff has yet addressed this discrepancy with the nurse who recorded the observations.
2. When Mrs Serkes’ treating consultant gynaecological surgeon attended her at 10.30am on Saturday, 23 July, he formed the impression that he was the first person to diagnose the stroke.
In fact, her son and another doctor had already discussed the stroke, and her son was under the impression that they were simply waiting for an ambulance to transfer to the Royal London Hospital. (He was already making arrangements to drive his father there.) None of this is recorded in the medical notes.
3. The decision was made by, at the latest 10.30am, but quite possibly an hour before then, to transfer Mrs Serkes to the Royal London Hospital for specialist care, but transfer was not effected until 2.07pm.
Stroke is an emergency.
4. Patient controlled administration of pain relief was arranged for Mrs Serkes, but she remained in pain. It was quite some time before it was recognised that the device was not connected and so was not delivering any analgesia.
5. Mrs Serkes’ surgeon went to the Royal London Hospital to see her at 10.30pm on Saturday, 23 July. He described in court palpating her abdomen and there being no rigidity, guarding, or further distension.
However, he made no record in the medical notes of his attendance and examination.
6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre.
However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active.
When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day.
After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital.
He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated.
He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that.
7. The surgeon suggested that perhaps bloods should be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this.
Some five months on, no member of staff has yet addressed this discrepancy with the nurse who recorded the observations.
2. When Mrs Serkes’ treating consultant gynaecological surgeon attended her at 10.30am on Saturday, 23 July, he formed the impression that he was the first person to diagnose the stroke.
In fact, her son and another doctor had already discussed the stroke, and her son was under the impression that they were simply waiting for an ambulance to transfer to the Royal London Hospital. (He was already making arrangements to drive his father there.) None of this is recorded in the medical notes.
3. The decision was made by, at the latest 10.30am, but quite possibly an hour before then, to transfer Mrs Serkes to the Royal London Hospital for specialist care, but transfer was not effected until 2.07pm.
Stroke is an emergency.
4. Patient controlled administration of pain relief was arranged for Mrs Serkes, but she remained in pain. It was quite some time before it was recognised that the device was not connected and so was not delivering any analgesia.
5. Mrs Serkes’ surgeon went to the Royal London Hospital to see her at 10.30pm on Saturday, 23 July. He described in court palpating her abdomen and there being no rigidity, guarding, or further distension.
However, he made no record in the medical notes of his attendance and examination.
6. The same surgeon described in court his view that [static] imaging did not disclose any active bleeding and so there was no indication to return to theatre.
However, later in evidence he agreed that the scans simply showed a collection of blood and could not demonstrate whether the bleeding was active.
When I asked about the haemoglobin, he responded that at 3.04pm that afternoon, it was recorded as 7 (he said 7, not 70), having dropped from a normal level of 120. He explained that this result might have been available earlier, but the computers were down in the middle of the day.
After further discussion, the surgeon told me that, given the 8cm haematoma he had diagnosed at the beginning of the day (Saturday, 23 July), he now believes that more efforts should have been made to review the blood results earlier, and in any event before Mrs Serkes was transferred to the Royal London Hospital.
He said that if he had considered the blood results earlier in the day, he would have recognised a much bigger bleed than he actually appreciated.
He said that he would probably have advised a further laparotomy – though of course there is no way of knowing if Mrs Serkes would have survived that.
7. The surgeon suggested that perhaps bloods should be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this.
Responses
Action Taken
Barts Health NHS Trust has briefed medical staff on complete record-keeping, reiterated the availability of point-of-care tests, and is giving ongoing training to nursing staff in the use of PCA machines; a surgeon has been instructed to reflect on the incident at their next appraisal. (AI summary)
Barts Health NHS Trust has briefed medical staff on complete record-keeping, reiterated the availability of point-of-care tests, and is giving ongoing training to nursing staff in the use of PCA machines; a surgeon has been instructed to reflect on the incident at their next appraisal. (AI summary)
View full response
Dear Ma'am, Inquest touching the death of Lita SERKES write in response to a Regulation 28, Report to Prevent Future Deaths, dated 16 December 2016, which was made at the conclusion of the inquest into the death of Lita Serkes. Barts Health NHS Trust takes Coronial investigations very seriously and am sorry you have had to make Preventing Future Death recommendations and am grateful to you for highlighting your concerns: note Lita Serkes died from a complication of a hysterectomy undertaken for endometrial cancer, that being a devastating bleed, the gravity of which was not immediately recognised: You have raised a number of concerns relating to the treatment received by Mrs Serkes_ The seven concerns you have raised in the Preventing Future Death report are: The discrepancy in the observation charts relating to Mrs Serkes being 'alert' has not been addressed with the member of staff who recorded them There was incomplete documentation in Mrs Serkes medical records. Mrs Serkes' treating consultant believed that he was the first person to diagnose the stroke, however, Mrs Serkes son had already discussed this with another doctor. This conversation was not recorded in the medical records
3. There was inadequate urgency in transferring Mrs Serkes to The Royal London Hospital on Saturday 23 July
2016. The decision was made to transfer Mrs Serkes at 10.30am but this was not effected until
102.07pm. Mrs Serkes Patient Controlled Analgesia (PCA) system was connected and this was not recognised for some time; leaving Mrs Serkes in pain: Barts Health NHS Trust: Newham General Hospital; The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross Hospital. 'D15ABL49 The not Nout 8
5. Mrs Serkes surgeon described in court physical examination that he carried out at The Royal London Hospital at 10.3Opm on Saturday 23 July 2016 the details of this were not documented in the medical records. You felt that there was an inadequate urgency in chasing the blood results; if these had been reviewed earlier in the the surgeon would have recognised that Mrs Serkes bleed was much bigger than he originally appreciated and he may have advised further surgery: The surgeon suggested that routine bloods be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this_ We have investigated the above concerns and can confirm: The requirement of making contemporaneous and accurate recording of patient observations been reiterated to all nursing staff via the Safety Huddle. The discrepancy in this instance has been discussed with the nurse in question and they have been asked to reflect on this incident and have been given appropriate training: All medical staff have been briefed on the requirement for complete and contemporaneous recording of all events in a patient's medical records.
3. The Trust recognises that stroke is an emergency and that you feel there was inadequate urgency in managing Mrs Serkes stroke: As a result the Trust is currently in the process of reviewing the hospital policy for the management of stroke and is also reviewing the checklist of advice given by the Hyperacute Stroke Unit. Trust is hoping that this will be completed by 01 April 2017. To ensure that this doesn't happen again, the pain team is giving on-going training to all nursing staff in the use of PCA machines.
5. It has been reiterated to the surgeon in question the importance and the requirement for complete and contemporaneous recording of all events in patient'$ medical records: He has also been instructed to reflect on this incident; to add it to his appraisal documentation and to discuss the incident at his next appraisal.
6. Again, the surgeon in question has been asked to reflect on this incident, to add to his appraisal documentation and to discuss at his next appraisal The Trust has reiterated to all medical staff the availability and option of using of care tests when managing deteriorating patients. These are tests that can be carried out at the of care ie. without having to send the sample to the laboratory: The Trust feels that by highlighting this option to all staff will ensure that investigations will be performed with the appropriate degree of urgency in the future. day has The point point
We can provide you with a copy of the Sl report once it is completed upon request; this will highlight the areas that we as a Trust felt could be improved upon in future and the steps that we are taking to do so. am once again grateful to you for bringing this case to my attention and hope this letter fully answers the concerns you have raised_
3. There was inadequate urgency in transferring Mrs Serkes to The Royal London Hospital on Saturday 23 July
2016. The decision was made to transfer Mrs Serkes at 10.30am but this was not effected until
102.07pm. Mrs Serkes Patient Controlled Analgesia (PCA) system was connected and this was not recognised for some time; leaving Mrs Serkes in pain: Barts Health NHS Trust: Newham General Hospital; The London Chest Hospital, The Royal London Hospital, St Bartholomew's Hospital and Whipps Cross Hospital. 'D15ABL49 The not Nout 8
5. Mrs Serkes surgeon described in court physical examination that he carried out at The Royal London Hospital at 10.3Opm on Saturday 23 July 2016 the details of this were not documented in the medical records. You felt that there was an inadequate urgency in chasing the blood results; if these had been reviewed earlier in the the surgeon would have recognised that Mrs Serkes bleed was much bigger than he originally appreciated and he may have advised further surgery: The surgeon suggested that routine bloods be taken routinely at 6am so that they are available for the ward round, though he was unsure whether the laboratory would be able to accommodate this_ We have investigated the above concerns and can confirm: The requirement of making contemporaneous and accurate recording of patient observations been reiterated to all nursing staff via the Safety Huddle. The discrepancy in this instance has been discussed with the nurse in question and they have been asked to reflect on this incident and have been given appropriate training: All medical staff have been briefed on the requirement for complete and contemporaneous recording of all events in a patient's medical records.
3. The Trust recognises that stroke is an emergency and that you feel there was inadequate urgency in managing Mrs Serkes stroke: As a result the Trust is currently in the process of reviewing the hospital policy for the management of stroke and is also reviewing the checklist of advice given by the Hyperacute Stroke Unit. Trust is hoping that this will be completed by 01 April 2017. To ensure that this doesn't happen again, the pain team is giving on-going training to all nursing staff in the use of PCA machines.
5. It has been reiterated to the surgeon in question the importance and the requirement for complete and contemporaneous recording of all events in patient'$ medical records: He has also been instructed to reflect on this incident; to add it to his appraisal documentation and to discuss the incident at his next appraisal.
6. Again, the surgeon in question has been asked to reflect on this incident, to add to his appraisal documentation and to discuss at his next appraisal The Trust has reiterated to all medical staff the availability and option of using of care tests when managing deteriorating patients. These are tests that can be carried out at the of care ie. without having to send the sample to the laboratory: The Trust feels that by highlighting this option to all staff will ensure that investigations will be performed with the appropriate degree of urgency in the future. day has The point point
We can provide you with a copy of the Sl report once it is completed upon request; this will highlight the areas that we as a Trust felt could be improved upon in future and the steps that we are taking to do so. am once again grateful to you for bringing this case to my attention and hope this letter fully answers the concerns you have raised_
Sent To
- Royal London Hospital
Response Status
Linked responses
1 of 1
56-Day Deadline
9 Apr 2017
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 27 July 2016 I commenced an investigation into the death of Lita Serkes, aged 80 years. The investigation concluded at the end of the inquest earlier today.
I made a determination at inquest that Lita Serkes died from a complication of a hysterectomy undertaken for endometrial cancer, being a devastating bleed, the gravity of which was not immediately recognised.
I recorded a medical cause of death of: 1a intra abdominal haemorrhage 1b total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial adenocarcinoma, on 22.07.16 diabetes mellitus, hypertension, right cerebral infarct
I made a determination at inquest that Lita Serkes died from a complication of a hysterectomy undertaken for endometrial cancer, being a devastating bleed, the gravity of which was not immediately recognised.
I recorded a medical cause of death of: 1a intra abdominal haemorrhage 1b total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial adenocarcinoma, on 22.07.16 diabetes mellitus, hypertension, right cerebral infarct
Circumstances of the Death
The surgery performed at Whipps Cross Hospital on Friday, 22 July 2016, was unremarkable. However, the following morning, Mrs Serkes suffered a stroke and was transferred to the Royal London Hospital. By that evening she was extremely unwell, and she died on Sunday, 24 July.
Copies Sent To
Care Quality Commission for England
, obstetrician and gynaecologist
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.