In a heartbreaking case that raises troubling questions about patient safety protocols, a coroner’s inquest has revealed that a series of hospital missteps contributed to the untimely death of 55-year-old Susan Evans. The tragedy unfolded in the wake of what should have been a routine weight loss surgery, but instead spiraled into a nightmare of uncontrolled sepsis and organ failure.
A Fatal Chain of Errors
The coroner’s report paints a chilling picture of how small oversights can snowball into deadly consequences when dealing with vulnerable post-surgical patients. The trouble began when Evans returned to Queen Alexandra Hospital just two days after her gastric bypass, complaining of worrisome abdominal pains.
Unbeknownst to Evans, her surgery had taken place on the first day of a junior doctors’ strike, leaving the hospital short-staffed and scrambling. To make matters worse, the hospital’s bariatric surgery department was critically understaffed, with the equivalent of only one full-time specialist nurse.
This skeletal staff soon made a grave error in judgment. Flouting the hospital’s own written policy, they sent Evans home without having her seen by the bariatric team or a senior doctor. This vital step could have caught the earliest warning signs of a rare but potentially lethal complication called an anastomotic leak.
Neither the written nor informal policy were followed in Ms Evans’ case.
– Coroner Sally Olsen
Missed Red Flags
Evans’ pain continued even as she was discharged, a red flag that went unheeded. When she returned to the hospital three days later, she was already critically ill with abdominal sepsis stemming from an anastomotic leak. Despite emergency surgeries, her condition deteriorated relentlessly until her death a month after the initial operation.
The coroner was unequivocal in her assessment, stating the hospital’s failings “contributed more than minimally” to Evans’ death. Had she been properly assessed by the bariatric team from the start, she likely would have been kept for observation, operated on sooner, and survived her ordeal.
Policies Disregarded
The most frustrating aspect of the case is that the hospital did have guidelines in place that should have prevented this outcome. But as the coroner pointedly observed, “Neither the written nor informal policy were followed.” This speaks to a concerning breakdown in patient safety culture.
It’s tempting to pin the blame on the junior doctors’ strike and staffing shortfall. But a truly resilient patient safety framework must be able to withstand predictable stresses. Strikes and staffing crunches cannot be allowed to erode the most basic safeguards.
Never Events
In the patient safety world, tragedies like Evans’ are sometimes dubbed “never events”—medical disasters that simply should not occur if proper protocols are followed. But time and again, we see the same stories play out: policies disregarded, red flags missed, and lives shattered.
The coroner has given the Portsmouth Hospitals University NHS Trust until February to explain how it will prevent similar incidents going forward. But the true solutions run deeper than any one policy or process tweak. They demand a top-to-bottom reexamination of how we weave safeguards into the fabric of medical care, and how we fortify them against the inevitable stresses.
A Daughter Lost
In the end, the greatest tragedy is a personal one. Susan Evans sought a healthier life through gastric bypass surgery. Instead, her family lost a daughter, a sister, a mother to an utterly preventable lapse in oversight. As her loved ones grieve, the medical system must confront uncomfortable questions about how tenuous its safety nets really are.
While no policy can erase their anguish, the greatest tribute to Susan Evans would be a reformed patient safety culture that truly lives up to its name—so that her story need never be repeated. Until then, her case stands as a wrenching reminder of the human faces behind the statistics, and the devastating cost when hospitals fail in their most fundamental duty of care.
