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Chief Executive’s Office
Trust Headquarters
Queen’s Hospital
Rom Valley Way
Romford
EssexRM7 0AG
DDI: 01708 435444
June 2013
To:
Healthwatch Members
Members of the Improving Patient Experience Group
Clinical Commissioning Group leads
Commissioning Support Unit for local CCGs
Directors of Adult Social Services
Director of Children’s Services
Members of Parliament
Overview and Scrutiny Committee members
Health and Wellbeing Board members
Dearcolleagues
Re:Maria De Jesus Inquest
An inquest has taken place into the death of Maria De Jesus, who died at Queen’s Hospital in November 2011.
The coroner’s verdict was as follows:
The pregnant deceased was admitted to hospital on 21stOctober 2011 complaining of abdominal pain. A diagnosis of appendicitis was made and an appendectomy carried out by trainee surgeons, in the absence of a consultant surgeon, on 23rd October 2011. The purported offending appendix was subsequently sent to the histopathology department. Discharge of the deceased took place on 31st October 2011 but she self-referred to hospital because of continuing abdominal pain on 7th November 2011. On 9th November 2011 it was discovered that the histopathology report (which had been available since 31st October 2011) confirmed no appendix was seen on microscopy. The following day, 100mls of pus was drained from the deceased’s abdomen. The next day after that she miscarried and later died on the operating table after a second, successful appendectomy. The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.
The Trust fully accepts his findings and has apologised unreservedly to Mrs De Jesus’ family for their loss.
The mistakes made are indefensible, and we admitted liability in this case at the earliest opportunity.
I would like to reassure you that full and detailed investigations have taken place, and an extensive action plan has been implemented which continues to be monitored. Wide-ranging work has taken place across the Trust to improve systems and patient safety aiming to prevent such a tragic incident happening again.
We worked with external investigators to draw up a report and list 30 recommendations, all of which have now been implemented.
These included:
- Supporting and developing clinical leadership in practice
- Providing better continuity of care from a named consultant and lead clinician for everyone admitted and through any subsequent admissions
- Implementing a specific policy to ensure that trainees are closely supervised at all times, including during surgery
- Ensuring a Consultant Surgeon and Consultant Anaesthetist operate on pregnant women, giving the very highest standards of expert care
- Ensuring the World Health Organisation surgical safety checklist is used at all times
- Developing and reviewing operational policies at every stage of a patient’s pathway
- Establishing more robust working mechanisms and relationships between different departments and services
- Embedding Standard Operating Procedures to ensure test results are picked up by the requesting clinician, and that unexpected or abnormal results are immediately reported by histopathology
If you would like more detailed information on the action plan and subsequent work which has taken place, I would be happy to share this with you.
As you know, a great deal of work has taken place over the past 18 months to drive up standards and the quality of care across the organisation. We continue to work hard to rebuild people’s confidence in our services and I appreciate your support.
Yours sincerely,
Averil Dongworth
Chief Executive