Hospital procedure review after death of patient (95)

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CARE procedures for patients after surgery at the Hospital have been reviewed following the death of an elderly Islander, an inquest has heard. Mabel Carter (95) died in hospital eight days after surgery on the hip that she had fractured in a fall at her residential home.


The inquest was told that various factors, including reduced staffing over a weekend and an inexperienced doctor being on duty, meant that she did not get a blood test which might have saved her life.

Deputy Viscount Advocate Mark Harris said: ‘One can’t help feeling that if Mrs Carter hadn’t had her recovery phase over the weekend, the outcome may have been different.’

Consultant orthopaedic surgeon Colin Dunlop, who is head of the orthopaedic department but did not perform the surgery on Mrs Carter, told the inquest that she had been admitted on a Monday afternoon in November 2017.

Mr Dunlop said that patients with hip fractures would ‘invariably’ be operated on, regardless of their age, with the aim that surgery would take place within 48 hours.

Mrs Carter’s operation was postponed twice, initially due to another emergency case over-running, and again the following day because her haemoglobin level had dropped, necessitating a blood transfusion.

Christina Claremont, Mrs Carter’s daughter, said that her mother had appeared ‘healthy and back to normal’ after the operation, but the inquest also heard that blood tests should have been taken on Saturday, 48 hours after surgery.

A busy weekend at the hospital, reduced cover and the fact that the junior doctor on duty was in only his second week after taking up his post, all contributed to the blood testing not taking place, the inquest heard.

Mrs Carter’s condition deteriorated on the Monday, a week after her fall, and she died four days later.


Mr Dunlop said it was impossible to say whether there would have been a different outcome if Mrs Carter’s blood had been tested as scheduled. Statistics showed there was a 10% chance of a patient dying as a result of such an operation, he added.

Pamela Le Sueur, clinical governance and risk manager at the hospital, outlined measures that were being introduced as a result of ‘learnings’ from the case.

The inquest heard that, as a result of the review, enhanced care had been provided since the appointment of a specialist orthogeriatric consultant, and that new clinical co-ordinators were providing additional support for colleagues.

Extra cover by junior doctors had been introduced on Saturdays and might also be brought in on Sundays, Mrs Le Sueur said. She also acknowledged Mrs Claremont’s observation that communication with patients’ families could be improved.

Born in England, Mrs Carter met her Jersey-born husband while serving with the Women’s Royal Air Force during the Second World War and subsequently moved to the Island, the inquest heard. She had lived at Stuart Court, in St Lawrence, for almost two years and was a popular character with staff and fellow residents at the home.

Advocate Harris recorded a verdict that Mrs Carter had died of acute cardiac failure due to haemorrhagic shock after fracturing her hip.


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