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Patient dies after bowel is nicked during heart surgery
A HEART patient died after an error made by a surgeon went undetected and his subsequent illness was misdiagnosed, an inquest heard.
Retired bio-chemist David Gilbert was having a triple heart bypass when a pair of forceps being used by consultant cardiac surgeon Theodore Velissaris perforated his bowel in two places, causing a severe infection.
But the subsequent deterioration in Mr Gilbert’s condition was misdiagnosed and he died a few days later.
They spoke out after Mr Velissaris told Southampton Coroner’s Court: “I had the wrong working diagnosis – I made a mistake.”
Mr Gilbert, 78, of Paddock Gardens, Lyming-ton, was suffering from heart disease and underwent surgery at the Spire on August 27 last year as part of a programme to cut waiting lists at the General.
But Mr Velissaris and his colleagues failed to spot that the patient was suffering from peritonitis – a potentially-fatal condition caused by bowel contents leaking into the abdomen – as his condition declined.
The inquest heard how Mr Gilbert began to experience severe abdominal pain and underwent exploratory surgery at Southampton General Hospital, where a larger team was available.
The two holes in his bowel were repaired and his abdomen was washed out, but he died on August 31, the inquest heard.
Describing Mr Gilbert’s heart bypass operation Mr Velissaris said the use of forceps was part of a routine procedure and said he didn’t “fully understand” how he perforated the duodenum.
He said: “I regret many things about this case. I wish I could turn the clock back and do things differently.”
Asked about the misdiagnosis he said: “I have had only one death in 200 patients.
“I take great care and great pride in my work but on this occasion I followed the wrong path.”
Mr Velissaris said Mr Gilbert appeared to be responding to the treatment, and added: “Every-one was comfortable with what was happening with him.”
But consultant pathologist Dr Victoria Elliott said he died of multiple organ failure after suffering a “cascade” of inflammation caused by the undiagnosed peritonitis.
Dr Neil Pearce, associate medical director of patient safety at the trust, carried out an investigation and concluded that changes could have been made to give Mr Gilbert the best chance.
One of Mr Gilbert’s two sons, Jon Gilbert, said his father “fell through a series of safety nets” and, with brother Richard, criticised the Spire for failing to tell them that he had been moved to the General.
Clare Forsyth, head of clinical services at the Spire, apologised and said: “If that was my dad I’d have wanted to know as soon as he became unwell.”
Recording a narrative verdict Southampton coroner Keith Wiseman said failing to recognise the perforation or interpret the correct clinical information led to Mr Gilbert’s death.
After the inquest Mr Gilbert’s family said they were seeking advice on whether to launch legal action.