More on KentOnline
The death of a 60-year-old managing director following a bowel cancer operation at Maidstone Hospital highlighted a number of failings with his care.
An inquest today ruled Sunil Sinha, a prominent figure in the fight against poverty, died of a known complication of a necessary medical procedure last February.
However, concerns were raised by assistant coroner Kate Thomas as to the standard of care provided by Maidstone and Tunbridge Wells NHS Trust.
The father-of-two, of The Common, Tunbridge Wells, underwent keyhole surgery to remove a tumour on Wednesday, February 4, 2015.
The operation went well and he did not require subsequent high dependency care and was transferred to a ward.
Over the course of the following evening his condition deteriorated, at 10pm his Patient at Risk score (PAR) was recorded as five although when later reviewed should have been an eight.
A nurse and doctor were alerted but no notes were taken. A later PAR score of one was not flagged up; such a significant change should have been passed on.
He required two blood transfusions and the court heard the on-duty locum doctor — who could not be tracked down by MTW to give evidence — was not clear on the procedure surrounding these and had to ask a nurse for assistance.
At 7.25am on Friday, February 6, he was sleeping peacefully. Just over half an hour later he went into cardiac arrest and did not recover.
A post mortem by Dr David Rouse revealed he died of haemorrhaging, it also found he was suffering from heart disease although this was not seen as a contributing factor.
Miss Thomas said there was a lack of compliance with Mr Sinha's care plan and hospital procedures, poor communication between staff and insufficient note taking.
While these were identified as failings she said it was not clear they contributed to Mr Sinha's death.
Evidence heard from MTW representatives during the inquest showed steps had been taken by the trust to address issues.
These included the introduction of a nerve centre which constantly monitors patients' conditions and automatically alerts staff of any significant changes.
There is also now a clinical crisis team who are on call all day, every day.
As a result Miss Thomas did not make a regulation 28 report to MTW. A report is required if failings still exist which could lead to deaths in the future.
Mr Sinha's son, Sahil, said: "This is a trust which has been in the news a lot recently and is of concern to most people across west Kent.
"We would like to see any lessons which come from this result in changes at Maidstone Hospital and across the country."
Mr Sinha leaves behind his wife Clare, daughter Priya and son Sahil.