Inquest finds “gross failure” in the care of a 77-year-old man who died after surgery at a Brighton hospital and could have survived had he been offered other treatments. 

An inquest at West Sussex, Brighton and Hove Coroner’s Court, has found there was a “gross failure” in the care of a 77-year-old grandfather who died after intestinal surgery at the Royal Sussex County Hospital in Brighton and that he could have survived if he was offered other treatments.

The inquest heard how the man was given no fluids for 24 hours after his major surgery, carried out by surgeon Marc Lamah. Doctors were unaware he had a history of heart problems, even though this information was recorded in his medical notes and he had previously received treatment for this condition at the same hospital.

In his narrative conclusion, assistant coroner Gareth Jones said the failure to provide the patient with intravenous fluids was a “gross failure”, but it did not amount to neglect.

The coroner also found that if the patient and his family had been given the option of another operation called a defunctioning stoma, he would have likely taken it, and he would have been more likely to have survived. The coroner did not accept Lamah’s evidence that he had offered this alternative operation. A second opinion could and should have been sought before the operation to remove the man’s colon was carried out, and another less invasive treatment should have been explored.

The hospital doctors’ failure to see notes that the left side of the patient’s heart only had 30% functionality was “absolutely appalling. Something as fundamental as previous heart issues should be easily available.”

Camilla Browne, associate solicitor from Leigh Day and who was acting for the family, confirmed that the coroner accepted that there was very strong evidence that the patient would not have wanted major surgery. “If he had been advised properly of his options, the coroner found that he would have been more likely to have survived. The coroner also found failures in his post-operative care,” she said. 

Not told of risks

The inquest heard how the patient had been adamant he did not want to have surgery for bowel problems he was experiencing in 2024. He was admitted to the Royal Sussex County Hospital after attending A&E at the end of May 2024, where tests initially found an ulcer. There were plans to discharge him, despite his family’s concerns that he was still unwell.

However, following a CT scan, a large mass was discovered on his intestine, and the patient was told he would need to have surgery to remove his colon. Neither he nor his family were told of the risks of this surgery, nor were they offered alternative treatment options which the coroner found would have increased the likelihood of him surviving.

Expert witness and surgeon, Stephen Brown, professor of surgery at Sheffield Teaching Hospitals and the University of Sheffield, told the inquest that the left side of the patient’s heart had only 30% functionality, which he described as a “significant compromise of cardiac function”. This information was included on the man’s medical records but was not noticed by the medical staff treating him in hospital.

Brown also said he found it “deeply concerning” that Mr Craig had received no intravenous (IV) fluids for 24 hours.

Stephen Drage, the hospital’s medical director for professional standards, told the coroner that he could not possibly argue that the lack of careful pre-operative assessment and post-operative fluid management was within a standard that is expected. He went on to say that he was not here to try and defend that.

The coroner issued a direction to University Hospitals Sussex, which runs the hospital, to provide a statement evidencing that the hospital’s consent processes have been improved. Should the coroner not be satisfied with the evidence provided, it is likely that he will issue a Prevention of Future Deaths Report.

University Hospitals Sussex said it would respond to the coroner’s findings “as a matter of urgency” and has apologised for failings in the man’s care.