Questions have been raised about the care of a woman who died five days after she had a routine operation to have her gall bladder removed.

The death of Tina Stone, a 57-year-old shop assistant, of Woodlands Road, Sittingbourne, was the subject of a serious case investigation.

A post mortem revealed she died due to multi-organ failure as a result of biliary sepsis, after the operation at Medway hospital on February 22.

The procedure was originally due to be done by key-hole surgery but was switched to open surgery because of the size of a stone in her gall bladder.

Assistant coroner Eileen Sproson heard evidence from Dr Nandita Divekar and Dr Rachel Krol, from the hospital’s Intensive Care Unit (ICU) and Dr Caris Grimes, the author of the investigation report, at a resumed inquest hearing at Canterbury Magistrates’ Court last week.

Dr Divekar said Mrs Stone was transferred to ICU from the Ocelot Ward on Sunday, February 24. She was “very, very unwell,” Dr Divekar said, so the team considered the possibility of a post-op bile leak or sepsis and assessed the possibility of taking her back to the operating theatre in case there was a bile leak biliary leak or sepsis.

A CT scan showed there was fluid – but not enough to be a leak, so it was not felt Mrs Stone needed further surgery, Dr Divekar said.

“But the fact was there,” she added, “she was really unwell”.

Dr Krol took over from Dr Divekar in ICU and met Mrs Stone on the Monday, three days after the operation. “She was critically unwell,” she said. “She was in multi-organ failure. It was immediately clear to me how unwell she was. I remember thinking if we did not find a reversal cause for the multi-organ failure that she wasn’t going to survive.”

Dr Krol said she saw some fluid around the area of the operation on the CT scan, but was told it was consistent with what someone would have had following an operation.

It was decided to operate again on February 25 to clean up the fluidbile that had leaked inside her from the remnant and had not been collected by the drains. She was also discovered to have another stone that had lodged in her common bile duct and Mrs Stone 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 husband Adrian and two sons, Ricki and Ross, Dr Caris Grimes, the author of the investigation report, listed some of the short-comings that “went wrong” with Mrs Stone’s care. They included her being admitted with gall bladder pain in May 2018 and staying on the waiting list, while her pain worsened, until her operation in February.

Dr Grimes said: “If she had been seen earlier she wouldn’t have ended up in quite the severe pain she was in and she may have been able to have had a keyhole operation.”

Another issue was that Mrs Stone’s had a pre-op assessment three days before the operation, which showed high levels of bilirubin in her blood – something Dr Grimes said the surgeons should have been aware of, as such levels raise question marks about whether to go ahead and operate or have more tests. No concerns had been raised as they had not seen the most recent results.

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