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Inquest concludes following unexpected death of patient with Alzheimer’s after knee surgery

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Medical law experts at Shoosmiths solicitors attended an inquest into the death of David Cowdrill (85) who died at Solihull Hospital on 3 June 2019 after failures in his care – specifically a failure to seek his consent for orthopaedic surgery following which he developed complications and died. At the inquest HM Coroner, Mr Ian Dreelan, concluded that the deceased died of recognised complications of surgery.

Mr Cowdrill’s daughter, Anita Bowker, explained that with support from his family, her father had been living independently in his own home prior to his death at Solihull Hospital. He suffered from arthritis from a motorbike accident when he was younger for which he had undergone a right total knee replacement in 2017. Following this surgery, he had experienced some difficulties with his walking.  He had been diagnosed four years ago as suffering from Alzheimer’s dementia for which he was receiving medication.

Delay in obtaining consent

At a hospital appointment on 29 January 2019 Mr Cowdrill was informed that he needed to undergo revision surgery to his right knee on account of some instability with the joint. At this appointment, only the risks relating to pain and function of the knee were discussed. The general risks of undergoing this type of major surgery under general anaesthetic were not discussed and his consent for the operation was not requested until more than five months later on the day of surgery.

After a number of cancellations, Mr Cowdrill finally underwent the three-hour knee operation on 23 May 2019. Mr Cowdrill’s daughter states that her father was asked to sign the consent form in a hurry after his glasses and hearing aids had been removed before the operation was carried out.

The inquest heard that in the days following the operation Mr Cowdrill became increasingly unwell with complications suffering from a paralytic ileus and e-coli pneumonia. Confusion and delirium then developed. Despite treatment attempts by hospital staff, Mr Cowdrill sadly did not recover, and he died in the early hours of 3 June 2019.

Serious Incident Report compiled

A Serious Incident Report compiled by University Hospitals Birmingham NHS Foundation Trust following Mr Cowdrill’s death revealed that the hospital’s policy for acquiring his consent for the surgery to be undertaken was not followed.  In particular, despite a documented and proven diagnosis of dementia, there was no formal mental capacity assessment carried out by the doctor at the outpatient appointment where Mr Cowdrill’s surgery was discussed, or by the nurse at his subsequent pre-operative assessment. Mr Cowdrill’s dementia and other health problems were not taken into account for either his ability to provide valid consent for surgery, or when discussing the risks and potential complications of the surgery which was undertaken under a general anaesthetic.

The report suggested a series of recommendations to ensure that all patients provide their consent to treatment. The report stated that all trauma and orthopaedic medical staff were to be reminded in writing of the Trust’s consent policy and the procedures which must be followed in the operating theatre and in the outpatient department when patients are seen. The Trust state that consent for treatment must be obtained in the outpatient department and that written information must be provided to patients and that all older adults must be properly screened by the GOALS service at the Trust as part of the consent and pre-operative assessment process to check that they have the mental capacity to give their consent before treatment is carried out.

Issues of consent addressed

Despite the recommendations in the Serious incident Report to improve services at the Trust, the family state that to date they have had no reassurance that these recommendations have been taken on board. Victoria Blankstone, an expert medical negligence lawyer at Shoosmiths, said:

‘The family have been devastated by the death of their father and have struggled to come to terms with his sudden and unexpected loss after what they understood at the time was a straightforward knee operation. The inquest has been an incredibly difficult time for the family, but they are relieved that their father’s death has been investigated and that they now have further answers about the events that resulted in such a tragic outcome. We will continue to work with the family as they further look to come to terms with what happened.’

Mr Cowdrill’s daughter, Anita, added:

‘Despite the Trust’s admitted failings in my father’s care, it has been very difficult to not to feel bitter or angry about what happened when my father went into hospital for surgery so that he had better movement with his knee. It is a tragedy that he died in such circumstances and so unexpectedly without his family being by his side. If we had known all the risks of the surgery which was going to be undertaken under a general anaesthetic, I know my father would not have chosen to undergo such a major procedure with all the additional difficulties he would have faced with rehabilitation afterwards.’

Victoria concluded:

‘Nothing can turn the clock back, but it gives the family some peace of mind to know that the admitted shortcomings in Mr Cowdrill’s care at the time of his treatment have led to lessons being learned by the Trust’s orthopaedic services to prevent similar incidents being repeated, and to protect other elderly frail patients when undergoing treatment they may not understand and for which they may require extra support.’

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