A WIDOW has told how her husband died after refusing to go the same hospital that had previously failed his father.
John Gilchrist, 57, died from a blood clot last November – less than a year after his dad Jim died following a botched operation at the Edinburgh Royal Infirmary.
The truck driver fell ill but refused to let his wife call him an ambulance because of “what that hospital did to dad”, and passed away at home in Pam’s arms.
His untimely death meant John did not live to see the ombudsman’s damning indictment of his father’s care in a report published yesterday – a year to the day after Jim died.
Retired Pam, 62, said John would have been glad to see justice prevail as health chiefs were denounced for a catalogue of “very serious failings” which had caused his dad “significant personal injustice”.
The 82-year-old died 20 months after he underwent an operation to repair an aneurysm in his abdomen at the Capital’s flagship hospital in September 2011.
During the procedure, surgeons found they did not have a vital piece of equipment to deal with a leakage of blood and had to wait four hours for it to be brought from Dundee. It meant the grandad’s operation took eight-and-a-half hours – double the time it should have.
The potentially catastrophic oversight was just the first in a series of blunders that lead NHS Lothian to issue an apology and review their working practices.
Jim’s family is under little doubt the initial surgery was the first in chain of events that saw an otherwise “fit and healthy” pensioner, deteriorate before their eyes.
“My father-in-law once said that in some ways he wished he’d never come out of the operation, that he’d never woken from the anaesthetic. At some points he was very ill, at time the infection was raging.
“For 20 months he couldn’t go anywhere, couldn’t walk, there was no way he was ever getting home. He should have been at home with Betty.
“John was so close to his father, so was his sister, and it was incredibly hard for all of them. I was hoping it would be resolved before Jim died and I certainly wasn’t expecting the other one.”
John collapsed and died at the home they shared in Leith, just six months short of the couple’s 25th wedding anniversary.
Pam believes the deep vein thrombosis could have been caused by his profession as a driver but he never allowed himself treatment because of his fear of the ERI.
He collapsed at the kitchen sink, struggling for breath two days after first feeling unwell, and Pam believes he had already died by the time paramedics arrived.
She said: “It might sound daft but it’s my opinion I might still have my husband if this had not happened. It has taken away so much from our family. I can’t get past that to be honest. I kept saying I should call an ambulance but he kept saying ‘you’re not taking me to hospital, look what it did to my dad’.
“He wasn’t the sort of man whose mind you could change, if he didn’t want to go, you weren’t going to get him there.
“It just feels like if all this hadn’t happened to his father, he wouldn’t have been so adamant he wasn’t going and they’d have stood a chance of saving him at least.
“We didn’t want it to happen to anyone else, which is why we started this. It has been a long haul, and when my husband died I was in two minds to give up, but I thought I owed it to him to keep going.”
The hospital was criticised for a series of failures in its care for John’s father.
When Jim was recovering on the ward after his operation, a nurse noticed that night that he could not move his legs but failed to inform doctors. He was also seen by a vascular surgeon and later a consultant surgeon who examined the pulse in one of his legs without picking up on his immobility.
The following day, another nurse noticed he could still not move his legs and alerted medical staff.
It was found that Jim had an epidural haematoma, a build- up of blood pressing on his spinal cord. A further operation to drain the fluid had no effect and he was left paralysed from the waist down.
“When Jim went in he was under the impression he’d be out quickly, we all were, but he never came home from hospital,” said Pam, from Leith.
“My husband and I went in with him, and his partner Betty, to settle him into the operation.
“It obviously took longer than it should have done because they didn’t have the part they should have had. We wondered what was going on because we had been told to phone at a certain time and he was still in the operating theatre, which didn’t sound good. I realised things weren’t right.
“Not having the right equipment for an operation is a massive oversight. It says in the report that they hadn’t required it since 2003 but it also says these things are a possibility and, as such, they should be there.
“It’s like having house insurance – you’re hoping the house won’t fall down, but it doesn’t mean you don’t need the insurance.
“As far as I understand it, they had to keep him under and pain-free until they got that piece of equipment. He was touch-and-go a few times, they didn’t know if he would make it. My husband was spitting feathers at the time, as you can imagine.”
Following the major surgery, Jim was initially hopeful that he would get movement back, but he had in fact developed a clot around the site where an epidural had been administered.
Two days after the initial procedure, when he was stable enough to be moved, he was transferred to the neurology unit at the Western General for emergency surgery to relieve the build of pressure on his spinal chord.
Attempts to drain the fluid failed and Jim, of Newtongrange, was placed in intensive care, and his family were told the next 48 hours were crucial. They were also warned the likelihood of his walking again were slim to none.
In December 2011, he was transferred to Liberton Hospital, where his mobility failed to improve and he subsequently developed a bedsore on his ankle. It became so infected, the following month he was forced to return to the ERI for surgery to amputate his lower left leg.
“He was extremely depressed, it was very sad to watch. Jim had always been such an active man, even though he was 82 years old, he was still able to walk on his own two legs. He used to go and have a little kickaround with his nephew but this was obviously no longer an option.
“He was full of life. He loved going on the Norfolk Broads, we were only there in 2010 so he was still capable of going on boats then. However, he went into the hospital in September 2011 and he never really came out again after that, sadly.”
The retired clerk of works, or site inspector, spent his final days in Midlothian Community Hospital, where his family said he received excellent care. He died on May 21 last year.
Family, including partner of many years, Betty Bishop, lodged an official complaint with NHS Lothian, but dismissed the initial response – with the board’s own investigation criticised in the ombudsman’s findings for not acknowledging “serious failures in assessment and communication by medical staff”.
The scathing report said the serious flaws in care included not ensuring the necessary equipment was available for the operation and failing to inform the patient fully of the risks. A number of recommendations were made, including that the board improve surgical safety and record-keeping and staff be re-trained where appropriate.
The ombudsman concluded: “Although I cannot say for sure that delays in detecting the haematoma resulted in Mr Gilchrist’s paralysis, a potential opportunity to successfully treat the problem was missed. This meant that Mr Gilchrist and his family endured extreme emotional and psychological distress.”
Sarah Ballard-Smith, nurse director for NHS Lothian, said: “I would like to express my sincere condolences to Mrs Gilchrist for the death of her father-in-law.
“We have accepted the recommendations from the Ombudsman, which include reinforcing the effectiveness of the surgical safety check list, re-emphasising the escalation and consent process and ensuring that relevant staff are aware of the vital importance of good record keeping.
“An action plan has been drafted and the points are being implemented as a matter of priority to prevent a repeat of similar failings.”
The ombudsman’s conclusions in full
“I concluded that several very serious failings led to a significant personal injustice to Mr A. These included not ensuring that all necessary equipment was available before the operation, or that the risks were fully explained in advance.
“There were a number of significant failings by staff to act on the fact that Mr A was unable to move his legs after the operation. Failures in record-keeping and to place Mr A in a properly appropriate ward after the operation also put him at risk.
“I am extremely concerned about all these failings and am very critical that the board’s investigation did not address such serious failures in assessment and communication by medical staff.
“Although I cannot say for sure that delays in detecting the haematoma resulted in Mr A’s paralysis, a potential opportunity to successfully treat the problem was missed. This meant that Mr A and his family endured extreme emotional and psychological distress.
“I made a number of recommendations to address this, which can be read in full in my report. These included apologising to Mrs C, taking action to improve surgical safety and record-keeping, and providing guidance on obtaining consent for surgical procedures.
“I also recommended that the failures identified are raised during the annual appraisal process of relevant staff and that the board address any training needs.”
Dr Jean Turner, Scotland Patients Association executive director: ‘When things go wrong, it’s just words to say sorry – even if you mean it.’
“There always is a risk no matter what your age if you are having that kind of surgery, but you would imagine that before they started anything like that they would have all the equipment.
“There were other things also in the report and I think the family must feel that, at long last, someone has said that it was not the best treatment and therefore the health board should learn lessons from it, and I hope they do.
“The whole point about listening to people’s complaints and concerns is that you learn from them and some of the things in that report happen time and time again.
“It’s quite a tragedy – so much can be done these days and the main aim is to keep people as well as possible and make sure they have the best quality of life before their natural end.
“It’s always a tragedy when somebody loses a life in these circumstances, but all people expect is that all that could be done was done and to the best of everybody’s ability.
“We know we don’t live forever and no doctor is infallible, but you expect the best attempt to look out for you.
“I’m delighted that the SPSO said what they said and the most important thing is that health boards do learn from mistakes, and they should listen to people.”