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'Misadventure' caused patient death at North Devon District Hospital

By North Devon Journal  |  Posted: November 01, 2012

A HOSPITAL "misadventure" led to the death of a patient at North Devon District Hospital, an inquest has heard.

Alden Gilson, from Chulmleigh, was 72 when he died following an operation in July of last year.

Mr Gilson was diagnosed with bowel cancer in October 2010 and underwent chemotherapy and was fitted with a colostomy bag as part of his treatment.

However, he became unhappy following the operation and went back to hospital in July 2011 to request that the colostomy bag be removed.

But complications with the surgery led to Mr Gilson developing an infection and as a result he died on August 11.

The inquest heard from Dr Anjum Arain, who performed the reversal at the request of Mr Gilson, who said the operation was carried out more for Mr Gilson's comfort than because it was necessary.

"The risks of surgery were clearly outlined to him," said Dr Arain.

"The second surgery was more for convenience than to save his life.

"From the surgical point of view it went very well. There was no concern from the operation. I do not have any cause as to why he developed this infection. Before he went for the operation, he did not have colitis."

When questioned by Dr David Thomas on behalf of Mr Gilson's family, Dr Arain said he had advised Mr Gilson to keep the colostomy bag in for a while longer before having it removed but said his patient was unhappy and was insistent that he wanted it taken out.

Dr Thomas replied: "As a consultant surgeon it is ultimately your decision. You would not want to put yourself into a position where you are being forced."

But Dr Arain claimed the patient is always right and that they must be listened to if they are experiencing problems.

Dr Thomas then asked the surgeon if he felt as though he had been put under unwarranted pressure to perform the reversal to which he replied that he had because Mr Gibson was very keen for it to be done.

The coroner also heard that Mr Gilson's wife had submitted a letter to the hospital following his death complaining about hygiene standards.

In particular she had concerns about the personal protection worn by staff and some of them did not wash their hands.

The letter also mentioned that the same cloth was used to clean multiple surfaces in the hospital ward.

But Fiona Baker, lead nurse for infection prevention and control at NDDH, stated that there was nothing wrong with the hospital's hygiene procedures although more could always be done to improve them.

Coroner Dr Elizabeth Earland summarised that the cause of death was renal failure and the infection Mr Gilson contracted as a result of his second surgery.

She said: "I am satisfied he would hot have died if it was not for that. The proper verdict for me to return is misadventure."

NDDH spokesman Glen Everton said: "The Trust regrets Mr Gilson's death, which resulted from a clostridium difficile infection following planned surgery.

"The verdict of misadventure indicates that this was an unintended outcome of the operation. Mr Gilson was very keen to have surgery to reverse his loop ileostomy, as he could not tolerate the stoma.

"Tests showed that he was suitable for the reversal.

"Following the operation, on 7 July 2011, he developed clostridium difficile colitis.

"Following the Trust's standard procedures, a Significant Event Audit was carried out. This confirmed there was no evidence that the infection had been acquired in hospital."

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