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A coroner who ruled a mother's death in hospital was not the result of neglect was met with an angry exchange from the patient's emotional family.
Tina Stone's husband and sons stormed out of an inquest at the Archbishop's Palace in Maidstone after an expletive-laden outburst in which they called Eileen Sproson an "idiot" and a "liar" and said she "should be ashamed of yourself".
The relatives raised concerns about the care of Mrs Stone, a shop assistant from Woodlands Road, Sittingbourne, after a routine operation to have her gall bladder removed at Medway Maritime Hospital.
Dr Pankaj Gandhi, who carried out the procedure on Friday, February 22, had earlier told the inquest he was unable to close the remnant of the gall bladder properly, but had inserted two drains to take away any leaking bile.
She seemed to be improving after the operation, but by the Sunday, she was deteriorating - which surprised the surgeon as her liver function tests were normal at the time - as the inserted drains were not collecting any bile.
The 57-year-old was transferred to the intensive treatment unit and treated for pancreatitis and then on the Monday, Dr Gandhi went in on his day off to check on the patient.
She was in a bad way and it was decided to operate again. She was found to have 750ml of bile inside her that had leaked from the remnant and had not been collected by the drains.
She was also discovered to have a further stone that had lodged in her common bile duct.
Following the second operation, Mrs Stone again initially showed signs of improvement, but then suddenly deteriorated and died on Wednesday, February 27.
Under questioning from the coroner and from Mrs Stone's family, it was established the patient had not been given an MRI scan since the previous May, which was the reason why the size of her gall bladder stone was so unexpected and the stone in the bile duct had not been identified.
Furthermore the registrar who carried out a pre-op assessment did not look at her most recent set of blood tests, but had examined an earlier set from December that had raised no concerns.
The more recent set indicated that she had an elevated level of bilirubin in her blood which should have flagged up warning signs.
"We apologise to the family that our pre-operative checks were not carried out to the standard that we expect" - James Devine, chief executive of Medway NHS Foundation Trust
When Mrs Sproson said in summary that blood tests had been carried out, Mrs Stone's family interjected and said they hadn't, calling the coroner an "idiot", and a "liar".
The relatives were then asked to leave the court, and said on the way out: "It's shocking, you clearly haven't listened to anything over the last hearings," followed by a string of expletives.
Mrs Stone's son added: "It's a shambles, you should be ashamed of yourself. If you have children, I hope they die in the same situation."
The family had earlier said they felt the level of care Mrs Stone received over the weekend was very low - they pointed out that according to her records her condition had not been checked between 7pm on Saturday night and 4am the next day.
Her son suggested that if his mother had not been unlucky enough to have had her operation on a Friday, she might still have been alive.
Dr Gandhi insisted that medical care was 24-hours and that every patient was examined by the duty consultant even on Saturday and Sunday.
Mrs Sproson delivered a narrative conclusion and said Mrs Stone died as a result of an undetected bile duct stone.
She told the court that while hindsight showed things should have been done differently, it did not amount to gross failures, and therefore not neglect.
James Devine, chief executive of Medway NHS Foundation Trust, which runs the Gillingham hospital, said: “We would like to again express our sincere condolences to the family of Mrs Stone on their sad loss.
"This was a complex medical situation where a number of factors were identified as contributing to her death following a cholecystectomy operation in February 2019 and unexpected complications which followed that surgery.
"We apologise to the family that our pre-operative checks were not carried out to the standard that we expect.
"We shall be considering the coroner’s findings carefully and she will be writing to us to obtain appropriate assurance that the lessons learnt in this instance are taken on board to improve the safe care of all our patients.”
