Coroner finds "very serious failings" in care of grandmother at Basildon Hospital

Lyn O’Reilly suffered the fatal infection after a bowel operation at the hospital.

Lyn O’Reilly suffered the fatal infection after a bowel operation at the hospital.

First published in News

A MUCH-LOVED mother and grandmother died after doctors at Basildon Hospital failed to notice she had serious infection, an inquest has ruled.

Lyn O’Reilly, 57, suffered the fatal infection after a bowel operation, at the hospital, but senior consultants failed to pick it – mainly because they were relying on inexperienced junior doctors.

An inquest into her death, on August 31, 2012, was told the junior doctors, looking after her had only been in the job for four weeks.

For some of her time in hospital, a single junior doctor was left alone to care for 130 patients on the night shift – something which, even now, remains standard practice at the hospital.

Yesterday, Essex coroner Caroline Beasley-Murray called for a ban on junior doctors being left unsupervised at night.

The inquest was told “a window of opportunity” to save Mrs O’Reilly was missed and her medical notes were “a shambles”.

Mrs Beasley-Murray, said: “There were very serious failings in the post-operative care Mrs O’Reilly received at Basildon Hospital.”

The inquest heard junior doctors had raised concerns about her condition, but these had not been acted upon by consultants.

Junior staff were given only minimal support, day or night time by more senior doctors.

Communication between nurses and doctors was also poor, another reason why the deterioration in MrsO’Reilly’s condition was not acted upon.

The coroner was told poor notes meant it was not clear if a senior consultant had reviewedMrs O’Reilly’s case on the morning of her death. It appeared she had “probably not” been reviewed.

Mrs O’Reilly was found collapsed in the hospital toilets, after days of complaining of being in pain. Nurses performed CPR for 25 minutes, but were unable to save her.

Apost-mortem examination found fluid in her abdomen, caused by an abscess which had burst and led to the fatal infection.

Independent expert Jonathan Refson said: “If a senior registrar had reviewed Mrs O’Reilly on August 30, they would have thought something was not right.

“Personally, I would have arranged an urgent CT scan. If that had been done, she would have had a different management plan. Acting first thing in the morning would have made a difference.”

Mrs Beasley-Murray recorded a narrative verdict and added: “The standard of documentation was woefully inadequate.”

She added she had already raised concerns about similar shortcomings with medical notes in past cases and planned to write a detailed report to hospital managers, outlining how she thought they needed to improve.

Comments (1)

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7:06pm Thu 16 Jan 14

missb36 says...

I am very sad to have read this story due to the fact that me and my family lost a sister in 2005 in basildon hospital with the exact same thing. My sister was 51 and had a bowel operation on september 30th, on the 10th day after we saw signs that she was deteriating and we questioned this everyday, we were assured by medical staff that whatever was wrong was nothing to do with the surgery that had taken place, on the 14th day i went to see her only to be told that they needed to do emergency surgery that night or she would die. They operated at 12 o'clock that night and it turned out that where they had stapled the bowel it had split and she ended up with peritonitis her body was full off poison, they flushed through 14 litres of saline in her body sadly she died in intensive care 7 days later of a stroke we had to turn her life support off. It took me 5 years to fight this and get Basildon hospital to admit mistakes had been made, her senior registrar said that had he seen my sister before that 10th day he would have known things weren't right and he felt that his junior medical team had let him down. As a family we just wanted to make sure that this never happened again and they said that things will be put into place to make sure it doesn't, well nothings changed has it, my heart goes out to the family as i know that they will never get over it as we still question why even now, we miss our sister and know that she should be here today but because of there mistake shes not and you cant bring them back and all we got was a sorry, the care quality commission said that there were grave failings in medical reports and lack of communication, even if i was on my last legs i would never go to that hospital again through fear of not coming out. To the family all i can say is time is a healer and to stick together, thinking of you.
I am very sad to have read this story due to the fact that me and my family lost a sister in 2005 in basildon hospital with the exact same thing. My sister was 51 and had a bowel operation on september 30th, on the 10th day after we saw signs that she was deteriating and we questioned this everyday, we were assured by medical staff that whatever was wrong was nothing to do with the surgery that had taken place, on the 14th day i went to see her only to be told that they needed to do emergency surgery that night or she would die. They operated at 12 o'clock that night and it turned out that where they had stapled the bowel it had split and she ended up with peritonitis her body was full off poison, they flushed through 14 litres of saline in her body sadly she died in intensive care 7 days later of a stroke we had to turn her life support off. It took me 5 years to fight this and get Basildon hospital to admit mistakes had been made, her senior registrar said that had he seen my sister before that 10th day he would have known things weren't right and he felt that his junior medical team had let him down. As a family we just wanted to make sure that this never happened again and they said that things will be put into place to make sure it doesn't, well nothings changed has it, my heart goes out to the family as i know that they will never get over it as we still question why even now, we miss our sister and know that she should be here today but because of there mistake shes not and you cant bring them back and all we got was a sorry, the care quality commission said that there were grave failings in medical reports and lack of communication, even if i was on my last legs i would never go to that hospital again through fear of not coming out. To the family all i can say is time is a healer and to stick together, thinking of you. missb36
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