A hospital has been criticised by a coroner after a 37 year old woman died after suffering complications from malnutrition. The problems all started when the woman went in to hospital with painful symptoms 8 years earlier and was diagnosed with cancer.
The cancer diagnosis meant that the woman had invasive surgery called a Whipple’s procedure whereby the surgeon removes the head of the pancreas, the gallbladder, part of the duodenum (small intestine), a small portion of the stomach and the lymph nodes near the head of the pancreas.
This major surgery can have complications and for the patient it cause her numerous health problems post surgery. It was later discovered, after analysing the biopsies from the operation, that the woman did not have cancer at all but in fact had a gall stone.
A coroners inquest criticised the hospitals care and stated that the patient failed to recover from major surgery, one complication being that she became malnourished.
As a result of chronic malnutrition she was also prone to infection and was in and out of hospital in 2013 but the coroner found that the hospital had failed to follow up on a referral and did not monitor her weight and her food charts effectively and felt that her life could have been prolonged.
The coroner said: “The treatment ……. received particularly in the later admissions leading to her death were below standard. Protocols were not followed.
“Weight loss was clearly there and yet the malnutrition was simply not tackled to the degree it should have been.
“I’m satisfied the operation in 2006 was the cause of the post-operative issues …….. suffered.
“I have no criticism whatsoever of the operation taking place and it is clear …….. never really recovered from the operation.
“I cannot understand why malnutrition was not treated more effectively.
“Whist I acknowledge ………… death may not have been avoided if protocols had been observed, it is clear to me the later part of her life in particular was particularly distressful and her life expectancy could have been extended if protocols that clearly were in existence had been followed.
“I therefore conclude the care attributed to ……… immediately before her death was lower than the acceptable standard and this accelerated her demise.”
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