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The sons of a 57-year-old who died after a medic consulted the wrong blood tests have said their mother would still be alive if it wasn't for the mistakes.
Medway Maritime Hospital, in Gillingham, has now been asked to provide arguments as to why a coroner should not reach a verdict of neglect in a patient's inquest.
Coroner Eileen Sproson's remarks came on Tuesday at the end of the third day of evidence into the death of Tina Stone, a 57-year-old shop assistant from Woodlands Road, Sittingbourne.
Mrs Stone died on February 27 just five days after she had a cholecystectomy - a routine operation to have her gall bladder removed. Her family - husband Adrian and sons Ricki and Ross - are convinced that Mrs Stone would still be alive had it not been for errors made during her care.
Principal among them was that the registrar who carried out a pre-op assessment on Mrs Stone in February did not look at her most recent set of blood tests available, instead looking at an earlier set from December that had raised no concerns.
Had he looked at the most recent tests, he would have realised that Mrs Stone had an elevated level of bilirubin in her blood which should have flagged up warning signs.
Additionally, the surgeon Dr Pankaj Gandhi who carried out the operation, removed a large stone from Mrs Stone's gallbladder, but was unaware that there was an additional stone in her bile duct.
It was this second stone, which blocked the duct and later caused as leakage of bile into Mrs Stone's abdomen that led to sepsis and her death from multi-organ failure.
During the hearing, it emerged that Mrs Stone, whose operation had been cancelled several times, had not been given an MRI scan since the previous May. Had she been given a more recent scan it would likely have revealed the presence of the second stone.
D r Gandhi admitted that if he had known the bilirubin levels were elevated, he "probably would not have operated. I would have explored more and got an up-to-date MRI scan."
Mrs Stone's sons argued that the repeated cancellation and postponement of her operation itself also amounted to neglect, since it took her outside the NHS's own 100-day guidelines for the operation and allowed the stone in her gallbladder to grow to such as size that Dr Gandhi had to convert from keyhole surgery to open surgery on the operating table.
The inquest spent a lot of time investigating whether drains placed inside Mrs Stone by Dr Gandhi following the operation were in the right place and were working properly, since they did not collect any bile.
But consultant general surgeon Brian Andrews who cared for Mrs Stone following her operation explained that the drains were collecting serosanguineous liquid and so were working. When Mrs Stone underwent a second operation to investigate why her condition was deteriorating, he observed that the drains were correctly placed.
Before the second operation Mr Andrews had concluded that Mrs Stone's deteriorating health was due to pancreatitis and was treating her accordingly. At this stage, Mrs Stone was not showing any elevated bilirubin levels that might have indicated a problem with her bile duct, although at the second operation she was found to have 750ml of bile in her abdomen.
The inquest also heard expert evidence from Professor Ameet Patel from King's College Hospital in London, who was consulted by telephone by the doctors at Medway, when Mrs Stone's condition deteriorated.
He explained the apparent lack of bile collected in the drains followed by the discovery of a considerable amount of bile at the second operation by reference to a boiling kettle.
He said it was likely that at some stage the second stone had moved and blocked the bile duct, but the build-up of bile had nowhere to escape to because scarring had blocked the cystic duct. There was build-up of pressure until: "Suddenly it goes and a whole lot of bile comes out."
Mrs Stone's sons complained about the number of doctors involved in their mother's care and that there had not been one consistent presence to observe her changing state, but Professor Patel said "That is the new NHS. They are trying to put us all in teams.You will see one person in clinic and another surgery."
But Professor Patel agreed with the family that the failure to review the latest set of blood tests "had been an oversight."
Following Mrs Stone's death, the hospital appointed a supposedly independent doctor, Dr Caris Grimes, to carry out a "serious incident" investigation to see what went wrong.
But on the last day of the inquest, documents produced by Brian Andrews seemed to suggest that Dr Grimes had also been involved directly in Mrs Stone's treatment.
The coroner Eileen Sproson said she had heard previously heard evidence that Dr Grimes was independent of the case and so she would be seeking clarification on the matter from the NHS Trust.
Mrs Stone's son Ross told the coroner that his mother's death was "clear-cut neglect."
But Mrs Sproson told him that although the family had presented their views "eloquently and forcefully" throughout the inquest, she would have to reach her conclusion after considering case law.
She said: "For me to reach a conclusion of neglect requires me to find both that there was a gross failure in her care and that the failure was the cause of her death."
She gave Mr Sheath seven days to make representations and then the family would be given seven days to comment on them before she reached her conclusion.
After the hearing, James Devine, the chief executive of Medway NHS Foundation Trust, said: “This is a very complex case. We understand that the coroner will be writing to the trust for more information on the internal investigation that was carried out, and we will be responding to her directly.
“It would not be appropriate for us to comment any further until the coroner has made her written judgement.”
For more information on how we can report on inquests, click here.
