Kate O'Donnell
22 Jan 2024 · Coroner Clare Bailey · Teesside and Hartlepool
The coroner's concerns
1. non-attendance of colorectal surgeon
“Planning for the operation was poor and resulted in the non-attendance of a colorectal surgeon at the surgery”
2. incorrect prophylactic antibiotics
“The consultant urologist did not know the results of pre-surgery urine test results and subsequently prescribed incorrect prophylactic antibiotics post urology surgery”
3. lack of knowledge of clean-contaminated classification and SIGN guidelines
“The consultant urologist was not aware of the classification of surgeries and didn't know that surgery could be clean-contaminated. He did not know of the SIGN guidelines and that prophylactic antibiotics were highly recommended for this type of gastro-intestinal surgery”
4. insufficient vigilance and recognition of post-operative presentation
“There was insufficient vigilance and recognition given to [the deceased]'s post-operative presentation, considering [the deceased]'s vulnerabilities, comorbidities, and extensive past involvement with the medical teams”
5. lack of physical assessment prior to discharge
“[the deceased] was not physically assessed by a doctor prior to discharge”
6. incomplete nursing notes
“The nursing notes did not include relevant information, to include [the deceased] vomiting and that she was in pain. The pain scores were under stated”