Medical Law Experts Say New Policy Should Be Implemented Across The Entire NHS To Protect Patient Safety

By Helen MacGregor

An NHS Trust has changed its policies after a father-of-two died because medical staff failed to notice his throat was torn during surgery and gave him food and drink despite notes saying he should not be fed.

Dennis Edwards’ heartbroken family have now joined specialist medical lawyers at Irwin Mitchell representing them in welcoming the news that Shrewsbury and Telford Hospital NHS Trust has since implemented changes after admitting mistakes ultimately led to his death.

It is now the Trust’s policy for patients undergoing endoscopic procedures (where a camera is inserted down the throat inside the body), that they are not given food or drink via their mouth for a period of observation. This to ensure they have not suffered damage as feeding a patient with a damaged oesophagus can lead to irreparable damage.

The 73-year-old died in September 2010 because of failures to notice his oesophagus had been damaged during an ERCP procedure to remove gallstones - a common complication. Alarmingly staff also later ignored a nil by mouth recommendation and gave him food and drink which leaked into his chest causing widespread damage and infection.

Dennis, from Bayston Hill in Shrewsbury, left behind his wife Jean, 68, and two daughters Diane, 46, and Julie, 43, who turned to medical law experts at Irwin Mitchell to help find answers about whether more could have been done to prevent the tragedy.

Now, the family say they feel Dennis’ death is no longer in vain after receiving an apology and reassurance that lessons have been learnt from the Chief Executive of the Trust, along with an admission of liability and undisclosed settlement for their loss.

Tom Riis-Bristow, a specialist medical negligence lawyer at Irwin Mitchell’s Birmingham office representing the family, said: “Dennis’ loved ones have been left devastated by his death and understandably wanted answers about why such unacceptable errors had been made.

“Damage to the oesophagus is a known complication of endoscopic surgery so medical staff involved with Dennis’ after-care should have been aware of the symptoms to look out for and recognised the importance of following a nil by mouth recommendation.

“We are pleased the Trust has now introduced the nil by mouth policy, where damage to the oesophagus is suspected, to ensure the same tragedy cannot happen again and we hope that this is shared across the entire NHS up and down the country in order to protect and improve patient safety.

“Whilst nothing can make up for the family’s loss, we hope that the settlement draws a line under the legal proceedings and allows them to begin rebuilding their lives.”

Dennis underwent the procedure at Shrewsbury Hospital on 10 August 2010 but the surgeon stopped halfway through as he was concerned he had caused damage to his oesophagus. He ordered liquid swallow x-rays which came back clear so Dennis was transferred to Telford’s Princess Royal Hospital for after-care.

He was given food and fluids, but the former water worker’s condition began deteriorating by the hour. It wasn’t until his daughter Diane pleaded with staff to help that further scans highlighted the damage and he was rushed to Queen Elizabeth Hospital in Birmingham. Sadly, despite emergency surgery, his condition deteriorated further and he later died on 21 September.

An investigation led by experts at Irwin Mitchell found a number of failings by staff at Telford Hospital including:

• A failure to consider perforated oesophagus as the cause of Dennis’ deteriorating condition, despite being aware that the surgeon had concerns that it may have happened and it was a common risk of the procedure;
• A failure to arrange a repeat chest scan to rule out damage to the oesophagus when Dennis’ condition continued deteriorating;
• A failure to note that an abdominal x-ray taken the day of the procedure showed signs of a possible oesophageal perforation.
• A failure to heed that Dennis was to be nil by mouth after there were concerns raised over his deterioration.

Jean Edwards, Dennis’ wife said: “We have always been a close family and after Dennis passed away, we found it very hard to come to terms with what had happened. He suffered greatly in the final weeks of his life and it was so frustrating not being able to do anything to help.

“My family and I feel that if more care was taken and information passed more easily from one hospital to another, Dennis’ condition would have been diagnosed earlier, giving him a much better chance of survival.

“For a long time we have been very angry about the fact Dennis was taken from us but we do now finally have some peace of mind that his death wasn’t in vain due to the Trust implementing new policies to stop the same mistakes being made again.

“It won’t bring him back but it’s some relief to know lessons have been learnt and other patients are now less at risk.

“We would also like to thank the medical team at the Queen Elizabeth Hospital for trying everything to save Dennis. We are most grateful to all the nurses on the critical care unit who each day looked after Dennis and did a very professional and dignified job. They always had time to tell us what was going on everyday even up to the end.

“We would like to thank friends who over the past two and half years have given us there support through these difficult times, along with the legal team at Irwin Mitchell for a successful outcome in the case.”

Read more about Irwin Mitchell's expertise relating to surgery claims