Published: 10:16, 06 August 2019
| Updated: 12:03, 06 August 2019
A woman died five days after she had a routine operation to have her gall bladder removed.
The family of Tina Stone, a 57-year-old shop assistant from Woodlands Road, Sittingbourne, have raised concerns about her care at Medway Maritime Hospital.
A post mortem found the cause of death to be multi-organ failure as a result of biliary sepsis, following removal of her gall bladder.
Coroner Eileen Sproson heard evidence from Dr Pankaj Gandhi who carried out the operation on Friday, February 22.
He related how the operation was originally intended to be done by key-hole surgery, but he had to switch to open surgery because of the size of the stone in Mrs Stone's gallbladder.
Dr Gandi, who said he had been carrying out similar operations "20 or 30 times a year" for the past 16 years said that unusually he had been unable to close the remnant of the gallbladder properly, but had inserted two drains to take away any leaking bile.
Dr Gandhi went off duty and Mrs Stone was left to recover on the ward. During the day on Saturday, she seemed to be improving, but by Sunday she was deteriorating, and the duty consultant phoned Dr Gandhi to discuss her symptoms.
Dr Gandhi said he was "very surprised" that Mrs Stone was unwell, and at the time her liver function tests were normal. The drains inserted by the doctor were not collecting any bile. She was transferred to the intensive treatment unit and treated for pancreatitis.
"It's difficult to cancel surgery for someone whose operation has already been cancelled a number of times..." Dr Gandhi
On Monday, Dr Gandhi went in on his day off to check on the patient. She was in a bad way and it was decided to operate again. She was found to have 750ml of bile inside her that had leaked from the remnant and had not been collected by the drains. She was also discovered to have a further stone that had lodged in her common bile duct.
Following the second operation, Mrs Stone again initially showed signs of improvement, but then suddenly deteriorated and died on Wednesday, February 27.
Under questioning from the coroner and from Mrs Stone's husband Adrian and two sons, it was established that Mrs Stone had not been given an MRI scan since the previous May, which was the reason why the size of her gallbladder stone was so unexpected and the stone in the bile duct had not been identified.
Furthermore the registrar who carried out a pre-op assessment did not look at her most recent set of blood tests, but had examined an earlier set from December that had raised no concerns.
The more recent set indicated that she had an elevated level of bilirubin in her blood which should have flagged up warning signs.
Dr Gandhi said he relied on his registrar and had assumed the pre-assessment was satisfactory.
Dr Gandhi admitted that if he had known the bilirubin levels were elevated, he "probably would not have operated. I would have explored more and got an up-to-date MRI scan."
But he added: "It's difficult to cancel surgery for someone whose operation has already been cancelled a number of times."
Mrs Stone's family questioned whether the doctor had placed the drains in the correct place. He insisted he had. Asked why they had not collected any bile, he said: "I don't know. There's no obvious explanation."
The family also felt that the level of care Mr Stone received over the weekend was very low - they pointed out that according to her records her condition had not been checked between 7pm on Saturday night and 4am the next day. Her son suggested that if his mother had not been unlucky enough to have had her operation on a Friday, she might still have been alive.
Dr Gandhi insisted that medical care was 24-hours and that every patient was examined by the duty consultant even on Saturday and Sunday.
The Medway NHS Foundation Trust was represented at the hearing by John Sheath from Brachers, who asked Dr Gandhi if he accepted the results of the hospital's serious case investigation.
Dr Gandhi said: "I do not accept that if the elevated bilirubin levels had been recognised at the time, that it would have automatically triggered an MRI scan."
At this stage, the court ran out of time, and the inquest was adjourned to a date yet to be determined.
The coroner intends to hear evidence from three other doctors and to hear about the hospital's own internal investigation, before she reaches a conclusion.