Maurice Cowling

Northern Lincolnshire and Goole NHS)

NHS Foundation Trust

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12 May 2015 Website www.nig.nhs.uk
Mr P Kelly
H M Senior Coroner for the District of Ren kt

North Lincolnshire & Grimsby aol Unit
Cleethorpes Town Hall
Knoll Street ant omer
CLEETHORPES Pee Bike oto
DN35 8LN
Dear Mr Kelly

Regulation 28: Report to prevent future deaths

Further to your letter of 13 March with enclosed Regulation 28 report, the Trust has now completed the
patient safety review of the three cases that you requested.

The report was issued following the death of three patients who had undergone hip surgery. A review of
the three cases has been undertaken, from both an anaesthetic and surgical perspective, by

Senior Consultant Orthopaedic Surgeon, and NE Consuitan Anaesthetist and
Associate Medical Director, in order to determine the need for any further Trust actions.

The outcome of the review is as follows:
Maurice Cowling

Mr Cowling died on 18 October 2013. He suffered from Parkinson's disease, dementia and atrial
fibrillation.

He was admitted to hospital with a fractured hip on 16 October 2013. He had recently been in hospital (in
September) with a chest infection and dehydration. Following this admission he had been discharged to
Gesham Lodge for respite care.

On admission to hospital on 16 October he was assessed by the Orthopaedic surgeons. A decision was
made to take him to theatre for surgery to fix the inter-trochanteric fracture of the left hip. The procedure
that was planned was a DHS fixation (dynamic hip screw). This is a very common procedure performed
in elderly patients who have suffered a fracture of this type. The surgery was then performed on the
afternoon of 17 October by a very experienced Staff Grade Orthopaedic surgeon who has carried out
hundreds of these procedures in the past. The surgeon noted that the bone density was ‘remarkable’ in
this particular case; drilling through the femur was very difficult. This resulted in the drill bit breaking. The
surgeon was able to see the broken drill bit on the screening x-ray. It then became clear that the patient
was bleeding. Advice was sought from a Consultant Orthopaedic Surgeon and the decision was made to
pack the wound in an effort to reduce the amount of bleeding and to call for assistance from the on-call
Consultant Vascular Surgeon. In the meantime the Consultant anaesthetist was taking all appropriate
steps to resuscitate the patient. This included blood transfusions and drugs to support the circulation.

ATeaching
Partner with

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we care,

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Our Trust is committed to clinical research and patients may be asked to take part in studies. a

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The provision of vascular surgery nationally is now based at regional centres (hubs). The nearest
regional centre for Scunthorpe General Hospital is Hull Royal Infirmary. The on-call Consultant Vascular
Surgeon on this day was working at Castle Hill Hospital and once contacted he immediately made his
way to SGH. A diagnosis of an injury to the profunda femoris artery was made and the damaged blood
vessel was repaired.

Despite all of the measures Mr Cowling suffered a cardiac arrest. As a result of his pre-existing co-
morbidity Mr Cowling had very little physiological reserve to cope with such a significant blood loss.
Following the surgery his condition deteriorated further and he sadly died shortly afterwards.

The Trust investigated this case as a Serious Untoward Incident (SUI) and, as you are aware, an
independent external opinion was obtained from a Consultant Orthopaedic Surgeon,

He confirmed that the injury sustained to the blood vessel is a rare but well recognised complication and
that the complication was also managed appropriately.

The SUI report made a number of recommendations in relation to minimising the risk of such an incident
occurring again and also ensuring staff are aware of what action needs to be taken in a similar case. |
am aware that the SUI report and action plan were shared with you ahead of the Inquest which was held.
| can also confirm that all actions are now complete.

Robert Connon

Mr Connon was operated upon at St Hugh’s Hospital. This hospital is managed by a different Trust and it
is therefore difficult for this Trust to comment upon the surgical aspects of this case. However, our
understanding is that Mr Connon was undergoing a different procedure, namely an elective total hip
replacement. This was performed on 28 July 2014. The hip joint was approached through a postero-
lateral incision. The surgeon then prepared the acetabulum in the usual manner and a cap was placed
in-situ and fixed with screws. The surgeon then went on to insert the stem into the femur. It seems as
though all was proceeding routinely until the anaesthetist, towards the end of the operation, informed the
surgeon that the patient's blood pressure had dropped when the hip had been reduced. At this point it
was not clear what the cause of the fall in blood pressure was but a number of potential causes were
considered including anaphylaxis (severe allergic reaction), pulmonary embolus, a cardiac event or
bleeding.

The anaesthetist felt that the patient needed to be cared for in an ITU and arrangements were therefore
made to transfer the patient to the Diana Princess of Wales Hospital in Grimsby.

Unfortunately, on arrival his condition was very poor and just a few minutes later he suffered a cardiac
arrest. Resuscitation was carried out successfully. He was found to be in complete heart block
(abnormal rhythm) and a temporary pacemaker was inserted. The precise cause of the patient’s collapse
still remained unclear but the possibility of vascular injury from the acetabular screw was something that
the surgeon and anaesthetist had raised as a possibility, and indeed treated the drop in haemoglobin
appropriately.

Despite full escalation by way of treat ent in ITU the patient's condition did not improve and he
deteriorated to the extent that he sufferéd another cardiac arrest and was confirmed deceased in the
early hours of the following day.

The subsequent post mortem revealed that the patient had an enlarged heart with severe triple vessel
coronary artery disease. The Pathologist also noted that there was a screw from the operation protruding
into the pelvis. This appeared to be at the epicentre of an extensive pelvic bleed. It was not possible for
the Pathologist to identify specifically which vessel the bleed had originated from because the arteries
were heavily calcified and difficult to cut. The Pathologist concluded that the cause of death was the
pelvic haemorrhage which had arisen as a result of the acetabular screw inserted during the operation.

From an anaesthetic point of view the Trust is of the opinion that all appropriate management was
undertaken when the patient was transferred to the DPOW from St Hugh’s Hospital. However, at that
stage he had already sustained a significant insult following the significant haemorrhage during the hip
surgery and, once again, the patient's physiological reserve was insufficient to tolerate this resulting in the
subsequent cardiac arrests and the patient's death.

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From an orthopaedic point of view it is relatively common for the acetabular screw to enter the pelvis
during this type of surgery but the haemorrhage which occurred here is not something that the surgeons
have previously encountered. The surgery was performed by a very experienced surgeon (a Consultant)
and the technique used was a standard one. Precisely why on this occasion there was such a significant
haemorrhage is very difficult to extablish. The Pathologist has noted that he was unable to identify the
blood vessel from which the bleed had originated because the arteries were heavily calcified, difficult to
cut and the site was obscured by blood clot. It is therefore difficult to conclude with any degree of
certainty why the haemorrhage occurred in this case. It has been assumed that the acetabular screw
must have damaged a blood vessel but the evidence to support this is not unequivocal given the fact that
the bleed did not become apparent for some time after insertion of the screws. Another possibility, given
the condition of the patient’s arteries, is that there may have been an abnormality of the blood vessel
such as an aneurysm.

Leonard Ireland

Mr Ireland was admitted to hospital on 18 June 2014 following a fall resulting in a fracture of his left hip.
He underwent a hemiarthroplasty on the following day.

It was noted that following the operation he was confused and aggressive, which had apparently not been
the situation prior to admission. The Mental Health Liaison Team were asked to review him and found
that he had been feeling low in mood and lacked motivation. Efforts were made to mobilise him and by
29 June he required minimal assistance to transfer to his chair. However, he was reluctant to mobilise.
He was then transferred to Bradley House for rehabilitation on or about 3 July.

He did not do well at Bradley House and became increasingly confused and violent. He was re-admitted
to hospital via the Accident & Emergency Department on 9 July. At this stage it was found that his hip
wound was leaking and infection was suspected. On admission to the ward he was also diagnosed with
a urinary tract infection. He was commenced on intravenous antibiotics and also taken to theatre that
same day for debridement of his wound along with the re-suturing. On the following day a VAC wound
dressing was applied.

There were problems administering his intravenous antibiotics as Mr Ireland repeatedly pulled out his
cannula. He was therefore commenced on oral antibiotics, eventually given in the form of a syrup.
Matters were further complicated by the fact that he had several falls from his bed since admission. He
also remained very agitated and aggressive, requiring the need for sedation. Compliance with his
medication was poor.

A second opinion was sought from another Consultant Orthopaedic Surgeon who felt that although the
wound appeared slightly red it was not grossly infected. The Mental Health Team was asked to see the
patient again on 20 July. They advised Lorazepam. The Consultant Orthopaedic Surgeon would ideally
have wished to perform a procedure to remove all the metalwork in the light of the infection but it was not
felt that he would survive such a procedure and the plan was therefore to treat him conservatively for the
time being.

The intention was to take him back to theatre on 30 July as his wound was gaping but his blood test
results (particularly his INR- clotting ratio) were very abnormal and the chances of him successfully
getting through any surgery were clearly poor. It was therefore decided that it would be in his best
interests to receive palliative care. He died on 12 August.

Mr Ireland suffered a recognised complication of his hemiarthroplasty, namely infection. This was despite
him being given prophylactic antibiotics. His behaviour on the ward after his surgery was challenging and
made it difficult to treat him effectively on occasions.

The review of the case has confirmed that the management of this patient was appropriate.
Unfortunately, it is not uncommon for patients with multiple co-morbidity to develop an infection following
this type of surgery despite staff using their best endeavours to try to prevent such a complication
occurring.

Summary

The Trust’s review of these cases has confirmed that the complications suffered by each of these three
patients were managed appropriately. The complication of haemorrhage suffered by Mr Cowling and Mr

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Connon is extremely rare. Despite the Trust carrying out hundreds of hip operations every year the
complication is not something the clinicians at the Trust had come across for some considerable time.
However, as set out by the independent expert in the case of Mr Cowling there is a recognised
complication rate of damage to the blood vessel although this is extremely rare. As for the complication
of infection suffered by Mr Ireland, this is far more common. All forms of surgery are associated with
post-operative infection and although all appropriate steps were taken to try to deal with the infection in
this particular case there is no doubt that the patient's pre-existing co-morbidity and his challenging
behaviour made treatment very difficult and in the end contributed to his death.

In conclusion, from the Trust's review it is felt that the Trust has in place appropriate arrangements to deal
with post-operative complications of the nature experienced. Whilst no further specific actions have been
identified, this will be kept under review.

| hope that you are satisfied that the Trust has carried out a full review into the deaths of these three
patients and that we have managed to allay any concerns following the Inquests. However, if there are
any issues which you still require addressing then please do not hesitate to contact me.

Yours sincerely

Mrs Karen Jackson
Chief Executive