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Hospital failed to spot how ill Winchester patient was, inquest hears
A SENIOR doctor has publicly apologised to the family of a woman who died at the Royal Hampshire County Hospital after staff failed to spot how ill she was.
Dr Andrew Bishop, chief medical officer for Hampshire Hospitals’ NHS Foundation Trust (HHFT), spoke to the family of Karen Spatcher at her inquest last week.
He said: “We failed to keep her safe. There are many causes of what happened, but none of those are excuses.
“There are two main questions: how can she have been so ill and us have not noticed that, and when we discovered that, how did we fail to save her?”
The inquest heard staff at the RHCH in Winchester failed to spot symptoms of internal organ damage.
Ms Spatcher was 46 when she died in December 2012.
She had suffered a slipped disk and was treated for back pain with prescription drugs from the Gratton Surgery, in Sutton Scotney.
She was then twice admitted to the RHCH, the second time on December 15, 2012, complaining of abdominal pain and severe constipation. She was treated for a urinary tract infection and given anti-inflammatory medication.
Due to a shortage of appropriate beds after a norovirus outbreak, Ms Spatcher, of Roberts Road, Barton Stacey, was moved from an acute ward to a treatment centre, which was designed for ‘short stay’ patients preparing for surgery.
Consequently she was missed off the Monday morning ward round, meaning no doctor saw her for 24 hours.
The inquest heard there was confusion about who was responsible for her care, and on the morning of Tuesday, December 18, she was rushed to have an emergency operation to relieve the pressure in her abdomen.
There she was anesthetised by Dr Jaco De Beurs, who admitted it was only the second time he had performed such emergency surgery.
Ms Spatcher, who moved to Barton Stacey in 1996 after marrying her then-husband, died when her heart rate dropped after a high dose of anaesthetic which aggravated the effects of her ruptured colon.
Doctors spent up to 40 minutes trying to revive her.
Her death prompted an investigation into the administration of anaesthetics at the hospital.
A family friend, Elaine Carr, paid tribute to the insurance manager. She said: “She was a vibrant, colourful and energetic person.
“Nothing fazed her — she had a few knock backs in her life and got on with stuff — she was a successful business woman. A big light has gone out in all of our lives and we will miss her every day.”
Her parents Iris and John Palmer, brother Simon Palmer, lifelong friend Evette Varey, and ex-husband, who did not wish to be named, were all present at the inquest.
South Central Hampshire Coroner Grahame Short returned a narrative verdict.
He said: “Her deteriorating condition on December 17 was not recognised due to: a; confusion about who was responsible for her care, b; the fact that she was placed in a day care treatment centre as a result of a shortage of beds at the time, c; a delay in diagnosis, and d; the excessive dose of the drug thiopentone used in anaesthetic induction.”
In a statement HHFT said: “Our sincere condolences go to Karen Spatcher’s family and friends.
“We are very sorry for the actions that led to her death. We have learned from this tragic incident and we worked fast to make real changes at the time.”