The coroner describes the failures of Spire Washington Hospital as “woeful” after appropriate observations were not undertaken before the patient’s discharge and medications were not given as expected.
Nicola Fisher underwent a gastric sleeve operation at Spire Washington Hospital, County Durham, and developed a leak from her stomach.
Following emergency NHS surgery in June 2023, less than two days after her discharge from the hospital, she underwent several more rounds of surgery at Sunderland Royal Hospital over the following seven months due to ongoing complications. Despite this, she died from multi-organ failure in January 2024.
At the inquest into her death at Sunderland Coroner’s Court, it was revealed that appropriate observations were not undertaken by nurses at the hospital before her discharge, and medications were not given as expected. The patient’s pre-discharge blood test results were also not checked prior to discharge.
Karin Welsh, acting senior coroner for Newcastle and North Tyneside, said that these failures were “woeful” and said it had hampered her attempts both to understand Fisher’s health at the time of her discharge and to establish whether there were missed opportunities to identify the leak and operate before she developed extensive infection in her abdomen.
Added complications
The surgery, on 12 June 2023, had the added complication of the removal of the existing gastric band – but Fisher was deemed fit to be discharged on the early evening of 13 June, although in the inquest it was revealed that she did not receive appropriate checks beforehand.
No leak test was carried out because it was not standard practice at Spire Washington Hospital, although it is done in many other healthcare settings, including in the NHS. Sunderland Royal Hospital would have done this, the inquest heard.
After experiencing symptoms of nausea before and at the point of discharge, Fisher contacted Spire Washington Hospital the following day – 14 June – to complain of vomiting and shortness of breath. While they offered to prescribe anti-sickness medication, an ambulance had to be called to take her to Sunderland Royal Hospital.
“The inquest has led to the identification of a series of basic failures on the part of Spire Washington Hospital, which may have presented missed opportunities to avoid her suffering and death,” said John Lowther, senior associate at Slater and Gordon, who is acting for the family.
