Coroner critical of treatment

letter from Ann Marr, chief executive of St Helens and Knowsley Teaching Hospitals NHS Trust
letter from Ann Marr, chief executive of St Helens and Knowsley Teaching Hospitals NHS Trust
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A CORONER has criticised the treatment of a Jehovah’s Witness who died following a routine hospital procedure.

Coroner Christopher Sumner told how Jean Gilman’s religion, which determined that she would never accept a blood transfusion, “was not generally made known” by Whiston Hospital staff.

He also reported that “little urgency was shown by treating clinicians” and that record-keeping was “poor” as the tragic 59-year-old bled to death.

Mrs Gilman, of Sutton Leach, a Jehovah’s Witness for almost 40 years, had been referred to the hospital by her GP in February 2009, suffering from shortness of breath.

A pleural aspiration procedure - aimed at removing fluid from her lungs - was carried out by Dr Mithun Murthy a week later.

However, the procedure, performed “blind” without the help of ultra sound, caused fatal damage to her left kidney and spleen, as well as internal abdominal bleeding.

Mrs Gilman’s husband, Peter, 62, said he was pleased that the hospital trust had accepted liability for his wife’s death, but added: “The doctor who botched the procedure still refuses to answer any questions about what he did.

“He has not expressed one word of sympathy to me or my family for the death of my wife nor has he expressed any remorse for getting it so wrong.”

Following the procedure, Mrs Gilman’s blood pressure started to plummet but Dr Laura Fadden, who had accompanied Dr Murthy during the procedure, failed to act.

Mr Sumner blasted Dr Fadden, saying he had “no doubt” that nurses had made her aware of the deterioration in Mrs Gilman’s health, despite her claims to the contrary.

Mrs Gilman was adamant that, due to her faith, she would not accept blood products - despite being warned that this put her life at risk.

And surgeon Mr Jha finally viewed the results of a subsequent CT scan at 11pm, despite a three-day inquest at Bootle Town Hall hearing that they had been ready almost an hour earlier.

Emergency surgery finally commenced at midnight.

Mrs Gilman died on March 10, 2009, from a haemorrhage and iatrogenic punctures of the left kidney and spleen.

Mr Sumner said a blood transfusion “might well have saved her life”.

A spokeswoman for the St Helens and Knowsley Teaching Hospital NHS Trust, who offered condolences to Mrs Gilman’s family, said: “Mrs Gilman underwent a procedure by a senior doctor who had performed this procedure many times and was competent to do so. Regrettably, on this occasion, he made a mistake.

“Following the incident Dr Murthy was suspended from all interventional activities and supervised by a consultant. He left the trust shortly afterwards.

“However, an immediate review of his clinical competence was undertaken which concluded that he had the knowledge, skills and training to carry out the procedure.”