Tragedy of hospital operation

During the insertion of a urethral catheter the patient's colon was perforated.

Coroner Alan Craze recorded a verdict of accidental death on 58-year-old Anthony Norris whose spinal tumour had gone undiagnosed for some time.

He said: "Something went wrong."

Tuesday's verdict came more than two years after Mr Norris died in the Conquest Hospital at Hastings.

The coroner said: "We are dealing with the sudden and unexpected death in extremely tragic circumstances of someone who was a comparatively young man."

He had no doubt that the cause of death was a perforation to the bowel which happened during a surgeon's attempt to insert the catheter.

The court, attended by Mr Norris's partner Teresa Knight and daughter Tamsin, heard how, following a fall, he was admitted to hospital with paralysis caused by spinal tumours on November 11, 2002.

Mr Norris, of Hastings Road, had already attended back pain clinic and accident and emergency on two occasions, but his condition - myeloma - had not been diagnosed.

An appointment had been made for MRI scan but this was not brought forward as requested.

It had instead been decided that his medication was not sufficiently controlling the pain, and the final judgement to keep him in or not was left to a physiotherapist depending on his level of mobility. Mr Norris was sent away.

As a result of falling at home, he returned to hospital and was sent to Hurstwood Park for emergency neurosurgery for multiple myeloma, after which he suffered post-operative embolism and was put on the anti-coagulant warfarin.

Transferred back to the Conquest, he was now paraplegic with a urethral catheter in place to drain away urine, as the natural function was lost.

To give the patient more control, consultant Mr Roger Plail inserted a supra-pubic catheter but two attempts were made before this was judged to be successful. It was during this process that perforation of the sigmoid colon occurred, according to the coroner.

He said: "All the evidence favours reinsertion as the event which opened up the perforation, but the first insertion provided the route for that to happen."

He later commented: "You can't have the benefit of invasive procedure without accepting that risk."

Mr Plail responded that this was a "dangerous" procedure, with a one to two per cent mortality rate in difficult cases, because of complications such as the patient's size, or condition of the bladder.

A week later it was discovered that the catheter had come out, and with that came the realisation that the colon was perforated, with faecal fluid leaking out.

Consultant haematologist Simon Weston-Smith had been supervising Mr Norris's treatment for myeloma, and described him as "well motivated" to deal with both the disease and the disability.

Mr Norris had by now undergone three courses of chemotherapy and coped "extremely well", he said. Knowing that a laparotomy (exploratory surgery) would be needed, Mr Weston-Smith took steps to reverse the effects of warfarin prior to surgery.

He ordered Vitamin K to be given intravenously but the court heard how a "failure" of communication between himself and Mr Plail, who had been operating that day (January 31, 2002) in Eastbourne, led to misunderstanding over the timing of the Vitamin K's effectiveness.

Representing the family, solicitor Peter Flory pointed out that protocol for the use of Vitamin K suggested maximum benefit in reversing anti-coagulents occurs after 24 hours.

However, the laparotomy to locate the bleeding from the perforation took place instead within a few hours.

Mr Norris continued to lose blood, and died on February 2.

In summarising his verdict of accidental death, Alan Craze said: "The use of the word 'accident' is not in any way judgemental."

"It's simply saying that death occurred because something went wrong."