Whittington Hospital 'failings' responsible for Osmond Brooks death

Published: 7 May, 2010
by JOSIE HINTON

“SIGNIFICANT failings” by staff at Whittington Hospital directly contributed to the death of a retired barber following a massive haemorrhage, a coroner has ruled.
Osmond Brooks, 72, died in August last year when an ulcer in his bowel erupted and he suffered an internal bleed 10 days after being admitted to the Archway hospital complaining of weight loss and constipation.
An inquest into Mr Brooks’ death heard how errors in communication between junior doctors and administration staff meant an “urgent” request for an endoscopy to check inside his bowel was ignored, meaning the ulcer was not detected. At the St Pancras inquest on Tuesday, consultant surgeon Alan Wilson admitted he had made “a mistake” by not personally checking the test had been done, as the junior doctors were only two weeks into their posts.
He told the court Mr Brooks, who lived in Tottenham, would have received very different care if doctors had been given the results of the endoscopy.
“Alarm bells would have gone off as we would have known the diagnosis,” he said. “The ulcer would have been injected, which might have prevented further haemorrhage.”

A serious untoward investigation carried out by the hospital recognised a “significant failure” in systems, partly caused by a quick change-over in staff.
Accepting these failures, Jennifer Worrall, clinical director of medicine, told the inquest that procedures surrounding endoscopies had been overhauled since Mr Brooks’ death.
“The trust has rewritten its clinical guidelines around how requests should be made,” she said.
Coroner Dr Andrew Reid recorded a verdict of death due to natural causes “to which a significant failure by the system to obtain an urgent endoscopy contributed”.  He said: “I accept this was a significant failing that did cause or contribute to the deceased’s death.
“If [the endoscopy] had been performed I accept that some treatment would have been given to try and stop the bleeding.
“Thereafter more aggressive surgical management would have been deployed. He would not have died from an untreated ulcer.”
Speaking to Mr Brooks’ daughter, Mr Wilson said: “This case has had a profound effect on me personally and it has also had a profound impact on the trust.
“It has resulted in very marked changes in policy. You can now get an endoscopy at the drop of a hat.”