Coroner criticises hospital at inquest of Jehovah's Witness

St. Helens Star, UK/December 22, 2011

A Jehovah's Witness whose condition deteriorated after a series of blunders and delays at Whiston Hospital would likely have survived had she not refused a blood transfusion, a coroner has ruled.

Jean Gilman, 59, died from a haemorrhage and punctures of her left kidney and spleen, injuries sustained during a diagnostic pleural aspiration, Coroner Christopher Sumner ruled following an inquest.

However, delivering his narrative verdict, Mr Sumner stated that after her condition worsened the Jehovah's Witness "in accordance with her faith, refused a blood transfusion which might well have saved her life".

Mrs Gilman, a grandmother from Sutton Heath, was admitted to the hospital in February 27, 2009 with shortness of breath and lethargy.

She underwent the diagnostic test, which sees a needle inserted between the ribs to drain fluid from the lungs, on March 6.

Dr Mithun Murthy made four unsuccessful attempts to perform the procedure and instead damaged the left kidney and spleen, resulting in abdominal bleeding.

In evidence to the hearing, expert witness Mr Munsch stated that Dr Murthy had made a "significant error" in misjudging the site of the procedure, but added it was a mistake that might have been made by experienced physicians. He said, in his opinion, the "actions were not negligent".

However, he suggested Mrs Gilman's chances of survival would have been improved "by appropriate management of her treatment and if action had been taken without delays".

Mr Sumner criticised the hospital's record keeping for Mrs Gilman, suggesting it was "poor" and information about her religion was not "generally made known".

He also condemned the hospital for the "little urgency shown by clinicians" after Mrs Gilman's condition worsened, saying Dr Laura Fadden, who had accompanied Dr Murthy for the original procedure, had failed to act when a nurse told her that the patient's blood pressure had dropped.

When Dr Fadden did contact a colleague, Dr Aideen Cronin, three and a half hours after Mrs Gilman had the procedure, she failed to mention about the drop in blood pressure, added the coroner.

Dr Cronin realised Mrs Gilman was suffering from internal bleeding and asked for a more senior clinician to visit her bedside but it took an hour for the doctor to attend, added Mr Sumner.

Mr Jha, a surgeon, was tasked with performing emergency surgery but wanted to wait for the results of a CT scan before starting the operation. This decision was questioned by expert witness Mr James.

According to Mr Sumner, it appeared the X-rays were ready at 10.05pm but it was not until 11pm that the surgeon saw the results.

Prior to surgery, Mrs Gilman's family was informed that she was placing her life at risk by refusing blood products.

However, Mrs Gilman was "adamant in her resolve" not to take blood products but agreed to the use of a cell saver, which would recycle any of her own blood.

When surgery did begin at midnight on March 7 it took longer than anticipated and she went into a critical condition, failed to recover and died four days later.

In evidence Mr Jha said he believed Mrs Gilman would have survived the injury had she allowed a transfusion to take place.

In a statement responding to Mr Sumner's findings, St Helens and Knowsley NHS Teaching Hospitals Trust, said: "The Trust would like to offer its sincere condolences to the family of the late Mrs Jean Gilman.

"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. Every effort was made to treat Mrs Gilman, but as a Jehovah's Witness, she decided not to accept blood products and sadly she died four days later.

"The coroner confirmed that a blood transfusion might well have saved her life.

"The doctor concerned no longer works at the Trust. 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.

"The Trust has already written to Mr Gilman expressing sincere apologies."

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