Patient’s death four years ago revealed ‘systemic medical failings’ at King George Hospital coroner finds
- Credit: Archant
The death of a King George Hospital patient after an “unnecessary scan” damaged his kidneys revealed “systemic medical failings” at the hospital, a coroner concluded.
On October 30, the inquest of family man and D-day veteran Stanley Babbs finally ended more than four years after his death on February 16, 2016.
During the inquest, one of the Goodmayes hospital’s own doctors described the radiology department that administered the scan on January 21 that year as “the worst in the country”.
The coroner ruled the 91-year-old died of multiple organ failure from sepsis but that the scan, which used a dye that damaged his kidneys, “led to a chain of events resulting in his death”.
His son Terry told the inquest Mr Babbs had previously been active, happy and in charge of caring for his wife of almost 70 years. She died less than a year after he did.
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Numerous doctors stated Mr Babbs should not have received a scan using contrast dye given his known health problems, especially as he was never told about the risk to his health.
Barking, Havering and Redbridge University Hospitals NHS Trust (BHRUT), which manages the hospital, has since made improvements to its radiology department.
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Coroner Nadia Persaud said: “This was not simply an error in judgement, I have heard evidence of systemic medical failings.
“A clinical lead described this as the worst radiology department in the country. It was in special measures and (nephrology consultant) Dr Ajith James raised concerns about the safety culture.”
The coroner was unable to question the two radiologists who signed off on Mr Babbs’ scan about their decision-making because, to this day, they have never been identified.
While both radiologists signed a paper form to approve the scan, the A4 sheets were both scanned as A5, cutting off part of the documents, and no physical copies have been produced.
Ms Persaud said: “To have two medical professionals involved in patient care, making decisions to expose a patient to a harmful substance, with no identification of either of them is extremely poor medical practice and evidence of dysfunction.
“There is no evidence of compliance with good medical record-keeping in this case. This is not a one-off error. From the evidence heard, it’s the way the system was designed.
“The trust should have taken steps to try to identify the radiologists concerned in their investigation.”
The inquest found there were no assessments of the risk to Mr Babbs’ health posed by the use of contrast dye, despite the fact he had kidney issues caused by diabetes which put him at risk.
Ms Persaud concluded that, if risk assessments were done, the scan “on the balance of probabilities would not have been performed and his death at that time would have been avoided”.
However, she found the referring clinician, Dr Waseem Ashraf, was not aware he was responsible for this assessment because protocol changes were not circulated properly.
There was also a serious delay in putting protocol changes into practice, since Mr Babbs was not treated according to protocols developed in 2012, three years before he was seen.
Ms Persaud said: “I have heard a great deal of evidence about improvements that have been made (at the hospital) since February 2016.
“The entire patient journey will (soon) be electronic, there will not be any paper documents to scan and clinicians will also complete forms on the IT system.”
She described how the trust had signed a contract last month to have its IT system “upgraded to the best possible software”, with the expectation this would be done in 2021.
The trust’s clinical lead for radiology Dr Mohamed Elsayad told the inquest that, while improvements were “still a work in progress”, there was now a “greater focus on safety” in the department.
Ms Persaud noted her only remaining concern was that it should be more clear who is responsible for deciding whether to use contrast dye for patients like Mr Babbs.
She said she would send her report on this issue to the trust’s chief executive and would expect a response within 56 days, unless they requested an extension.