On 11 February 2014 a 4 day inquest took place into the circumstances surrounding the death of Mrs Gwendolen Margaret Sanday Bingham, who died after a revision knee replacement at Harrogate District Hospital on 3 November 2012.
Mrs Bingham was described as a popular and vibrant 75-year-old woman from Otley. She had elective knee surgery on 17 October 2012. Prior to the surgery she was in good health and lived independently, the operation was straightforward with no complications expected.
However, her condition deteriorated over the weekend (20/21 October 2012) when signs of renal failure were not picked up and she subsequently suffered a heart attack and stroke that led to her death on 3 November 2012.
During the course of an internal investigation and inquest, evidence given by consultant pathologist Dr Lowe, supported by the Trust clinicians, was that failures in treatment during the weekend of 20/21 October on the balance of probabilities caused or materially contributed to Mrs Bingham’s death.
During the inquest Mr Fell, Coroner considered issues of the quality of care provided to Mrs Bingham. Oral evidence was given by 22 witness and 8 statements read and considered by the Coroner. The Trust by its internal investigation or during evidence acknowledged that the care afforded to Mrs Bingham fell short of expected standards.
A number of issues were identified:
- Ineffective and inconsistent handover
- Delay in communication of abnormal blood results
- Incomplete and inconsistent documentation
- Incomplete medical care at weekend. Evidence was heard from the nurses who expressed deep concern at the staffing levels and quality of nursing staff at that time exacerbated by reconfiguration of wards, sickness and training
- Failure to escalate Mrs Bingham to a more senior colleague
- Over reliance and misinterpretation of numerical risk stratification systems (Early Warning Scores)
- Failure to review medication that was nephrotoxic despite Mrs Bingham’s clinical deterioration
- Lack of patient dignity
Mrs Bingham’s death led to a review of staffing, procedures and policies and revised practice that has been introduced at Harrogate District Hospital that will hopefully minimise the likelihood such events happening again.
Mr Scullion, Medical Director of Harrogate District Hospital commented: The failings and recommendations that have arisen from this process have been accepted by the Trust Board.
As a direct result of this case, the Trust has reconsidered both policy and practice within the organisation. Dissemination of learning has been both open and far reaching. I undertake to ensure this learning continues. Not to do so would be both a professional failure for me, and an injustice to the memory of Gwendolen Bingham.
Mrs Nicki Harrington, daughter said: I believe this was an avoidable, tragic event that should not have happened: we should have complete faith and confidence in our hospitals and the medical profession when anyone goes in for anything including elective surgery. As a family we believe that we are clearer about what happened to Mum that weekend and hope that no other family has to go through the traumatic experience we have. Mum was such a lively, outgoing person and had the knee operation so that she could continue to lead an independent, active and full life, playing bowls and enjoying theatre trips with her partner, Brian, being with her children and 8 grandchildren as often as she could. Sadly, her life has been cut short and we are devastated and feel deprived of someone we loved dearly.
Julie Say, Head of Clinical negligence at Hodge Jones & Allen said: These tragic events could have been avoided had good practice been followed and proper procedures put in place providing a safe environment for patients at especially at weekends. The family are pleased that the Trust has accepted failures in Mrs Bingham’s care and believe that the practices and procedures will make Harrogate District Hospital a safer place for patients and that something positive arose out of these tragic events. The trust investigated the matter in a timely open manner that has gone some way to help family and friends deal with this devastating loss.
Speaking following the inquest, Dr David Scullion, Medical Director at Harrogate and District NHS Foundation Trust, said: We would like to express our deepest condolences and sincere apologies to the family of Mrs Bingham for the failings in the care provided to her. We accept the findings of the Coroner and acknowledge his conclusion. We have thoroughly investigated Mrs Bingham’s death and this has led to a detailed action plan being implemented.
We have already introduced a number of improvements. These include:
- More robust handover arrangements between clinicians;
- Changes to the automatic alert system for the communication of abnormal blood test results;
- Adopting the new National Early Warning Score system, a more sensitive system than we had before to identify and alert to a deterioration in a patient’s condition; and increasing the number of staff working on Wensleydale ward, including at weekends.