An inquest into the death of a 35-year-old father of 2 from Ryde has heard that there were a series of mistakes made in his care by Isle of Wight NHS Trust which significantly contributed to his death over 3 years ago.
Steven Hasler, who left behind 2 young daughters, was found dead at home on 14th February 2019. His death came just months after he had open-heart surgery at Southampton General Hospital to replace a defective heart valve which had been present since birth but had only recently started to cause him difficulties.
While the surgery in November 2018 went well, after returning home to the Isle of Wight, Steven felt that his chest wound was not healing properly and noticed worrying signs such as large amounts of blood and pus coming from the wound.
Due to his concerns, Steven attended A&E at St Mary’s Hospital in the evening of 7th December 2018. He was seen by various doctors including a senior general surgeon, and it was noted that he had developed a bacterial infection of his chest wound following recent open-heart surgery and had been experiencing shakes and shivers, which can be a sign of infection in the blood. Blood tests were also carried out that evening and revealed a very high C-reactive Protein (CRP) level, a marker of inflammation.
At the inquest last week, on 6th and 7th July 2022, Coroner Caroline Sumeray heard that whilst a healthy person’s CRP level would typically be under 5 mg/L, Steven’s CRP level on 7th December was 70 times higher – at 350 mg/L, having risen from 255 mg/L the previous week. That indicated Steven’s body was battling a significant infection and given his recent open-heart surgery, this was a complication which required specialist management under the cardiac surgeons.
The inquest heard that whilst the senior general surgeon who saw Steven recognised that the infection was outside of his expertise and that advice from cardiac surgeons was needed, with no cardiac surgery unit on the Island, he did not make the necessary telephone call because it was late at night and he did not want to wake the on-call cardiac surgeon at Southampton, which the coroner described as an error of judgment. Instead, he decided to ask his colleagues on the day shift the next morning to do so. In the meantime, Steven was discharged home after just 1 dose of intravenous antibiotics and given a 7-day course of tablet antibiotics.
What followed was a series of further errors which meant that the cardiac surgeons never became aware of the infection: the day team never contacted them despite written instructions on a handover sheet to do so, the senior general surgeon never chased it up and there were no systems in place at the Trust to ensure the necessary action had been taken. To make matters worse, the Discharge Summary sent from A&E to Steven’s GP practice, described as “woefully inadequate” by the Trust’s medical director, made no mention of the CRP results or the plan to contact Southampton. This meant that yet another opportunity, which would have allowed Steven’s GPs to rectify the failure to contact the specialists at Southampton, was missed.
Tragically, the independent cardiac surgery expert instructed by the coroner told the inquest that, if the cardiac surgeons at Southampton had been made aware of Steven’s infection, they would have arranged for urgent admission to Southampton Hospital for treatment with prolonged intravenous antibiotics and surgery to clean the wound and remove infected tissue, which would likely have prevented his death.
Instead, the limited antibiotics he received had little chance of resolving such a severe infection and, on 14th February 2019, Steven was found dead at home by Police. A post-mortem examination determined that the cause of his death was widespread sepsis due to endocarditis, an infection of the inner lining of the heart, and a periaortic leak/perforation which developed as a complication of his valve replacement for heart valve disease three months earlier.
At the inquest, the Trust told the coroner that, since Steven’s death, they have put in place measures to ensure more effective handover of information between staff on different shifts and emphasised to general surgical staff the potential dangers of chest wound infections following open-heart surgery. They are also working on ensuring discharge summaries sent to GPs include all of the key information from each A&E attendance, including planned next steps.
The coroner concluded that there were incomplete handovers of Steven’s medical care at St Mary’s Hospital and a failure to recognise the seriousness of his condition on 7th December 2018 which significantly contributed to his death. She also concluded that, had a suitably comprehensive discharge summary been given to Steven’s GP, that would also have likely led to onward referral to Southampton for appropriate treatment.
Steven’s family were represented by Rebecca Ridgeon, solicitor at Leigh Day, and Sebastian Naughton, barrister at Serjeants’ Inn.
Following the inquest, Steven’s family said:
“We were all aware of Steve’s underlying heart condition since he was born, but he never let it hold him back and, for most of his life, Steve was the fittest and strongest person we knew. He was the comedian of five siblings and made everyone around him laugh.
“When he started to get some symptoms from his heart condition and was told he needed open-heart surgery in 2018, Steve was very nervous, but he knew it was important to go ahead with the operation to get him back on his feet so that he could continue being an active Dad to his two kids, who meant the absolute world to him.
“We were relieved that the surgery seemed to go well, but Steve never got the chance to look after his children again because his chest wound struggled to heal and the infection was not properly treated.
“His death at such a young age came as a huge shock to the whole family and we feel he was badly let down by the doctors he saw at St Mary’s Hospital on 7 December 2018.
“Over three years later, we are pleased that the coroner and the Trust have recognised the errors which contributed to his death and, whilst it will not bring him back, we are glad that as a result, it seems that measures are being taken to improve medical services for other patients on the island.”
And so it continues, another death that could have been prevented if it were not for our woefully incapable hospital and it’s equally incompetent staff. Senior surgeon didn’t make the call to the on call doctor ” because it was late and he didn’t want to wake him up ” ? REALLY? that is the whole point of an ‘on call’ doctor .So, they trot out the same lame ” measures have now been put into place to prevent such things happening in future ” trouble is, they do keep happening – told me same story 2 years ago – when their incompetence killed a relative of mine..and here we are again – still incompetent, still making mistakes that end lives.
on the other hand – how many lives saved and people fixed up because of the work they do.
Perhaps everyone in the NHS just quits and says “sod it, I aint doing this job anymore” – then where will everyone go for healthcare?
That doesn’t make the state of it now ok though what about all of the others who aren’t receiving basic care and attention? Our care homes aren’t much better either, we are low diene on the scale in this country and we have the most elderly?
Exactly on call means on call! Unfortunately some of the surgeons are unapproachable and have reputations for being horrible to lower staff members. Thus shouldn’t in any shape or firm affect the way the care pathway is carried out. It speaks volumes if you ask me! It’s always the case, you can tell several members of the team information about a loved one but they always say yes yes I’ve written that down and I’ll put it in their notes and pass it all on. They never do, they certainly didn’t fir our dad. If was like ground gif day fur a month. Still haven’t resolved the original issue but luckily we gif him out before he died from incompetence
My wife died coz of their incompetence yet was unable to prove the fact. Useless is an understatement
I used to find it distasteful when people sue the NHS as it is us not ‘the person’ responsible who pays the price which would be more fitting.
However I can see why people do, as this is disgusting, and I wonder how many old people, with no young relatives to pursue shoddy, dangerous practices which cause their UNKNOWN timely death happen here.
Many say the Island is the place where the lesser quality professional medical staff are sent, and I do wonder if this is true.
All the people I have met at St Marys are really nice, but admin is a disgrace and lack of information being passed on is commonplace.
Sad tale indeed
If we had a bridge we would all be safer.
So sorry for that young man and his family.
We need a bridge and shut St Marys, my mother and father both had horrible deaths at St Marys, we have no faith in them and dread the thought of being in their care for anything.
Always say you want to go to a hospital on the mainland for your treatment when reffered.
This is the reason we need a bridge! I find people who say no to it haven’t a clue why we need it. It’s because we need access to proper hospital care, as St Mary’s in not capable of giving care that people need. And I feel for all them people who have cancer, and have to travel over to Southampton for chemotherapy. I can’t imagine what it must be like having to travel after that. But it’s not just that if you have a bad heart attack and the weather is bad you don’t stand a chance. So have we got to wait till all these No people to a bridge lose someone dear to them, because they was unable to get across for life saving surgery or treatment. The Isle of Wight is over populated to not have a fully functioning hospital!
And still we build more houses and invite more and more people over! We can’t cope now
Absolutely disgusting failing to do your job correctly reading notes on hand over of shift you would think that would be the first thing they do when they get into work but no it’s probably make a cup of tea sit and have a chat
Our hospital used to have integrity. Now it is a shameful excuse with no clear pathways of communication or handover and continuing care. We have experienced it recently and talking to so many others they have as well. It’s relentless. How many people have to suffer, have best misses and actually die before they are made to look at the system and get it together. It truly is shocking and it’s sadly getting worse. It’s a caring profession that actually doesn’t care at all. There are good people in there but they’re banging their heads against brick walls all the time, I know because I’ve been one of them. Thirteen yes was enough for me
Another tragedy caused by St Mary’s lack of specialists. If you possibly can, avoid St Mary’s. If you value your life !!