A CORONER has described a hospital ward as a “rudderless ship”, after a series of failures led to the death of patient who had been wrongfully discharged just two days earlier. 

Brighton and Hove senior coroner Veronica Hamilton-Deeley slammed Eastbourne District General Hospital, ruling grandfather Barry Tucker, from Ovingdean, would still be alive if he had not been sent home early from a urology ward. 

The 71-year-old had been unwell and vomiting days after a complex surgery to remove bladder cancer, before he was discharged and died from complications two days later on September 17 2017.

Ms Hamilton-Deeley identified many failings in the hospital’s care in her verdict at the end of a two day inquest:

  • “Rudderless” hospital wards had no senior consultants in charge
  • “Sub-standard” and “disgraceful” notes taken by doctors
  • Focus was on discharge “as soon as possible” and doctor took promotional picture with patient 

Giving a narrative verdict Ms Hamilton-Deeley ruled: “Mr Tucker died from multiple organ failure and septic shock following a combination of factors arising post surgery. “The circumstances were that Mr Tucker should not have been discharged on September 15. 

“He should have been given expert consultant and nursing care at the urology unit. He should have received a patient information leaflet after cystectomy. On the balance of probabilities had he received these he would not have died when he did."

The inquest heard Mr Tucker, who was described as fit and well for his age, had been admitted to the hospital to remove bladder cancer in an extensive procedure called radical cystectomy, on Monday, September 11. The surgery had gone well, but in the days following he had started to became unwell and started vomiting. He was discharged four days later on the Friday as part of the hospital’s “enhanced” recovery scheme, which aimed to get the patient discharged in a quicker time - five to seven days - than the traditional recovery period.

Mr Tucker’s wife, Rosalind, said her husband felt there was pressure to get him out early. She claimed a doctor joked with her husband, that he would break a record for discharge time for the operation, and the same doctor said “he was in charge” when concerns were raised by two nurses.

Miss Hamilton-Deeley said the absence of  senior consultants and nurses and their experience  hampered his recovery: “This was an inexperienced team that lacked steady authority of a consultant urologist knowledgeable in the procedure and recovery periods. He should not have been discharged when he was.” 

She also criticised “substandard” and “disgraceful” doctors notes” which were meant to be recording his recovery and “disastrous” uncompleted intravenous (IV) fluid charts. 
The coroner also raised the fact staff took Mr Tucker for a 30-minute walk - despite him not having any physiotherapy - which ended with staff making him pose for a picture for a promotional campaign. 

She added: “I think this rudderless ship was out of control on the stormy sea post his operation.”

Mr Tucker fell ill one day after being discharged at home, waking up suffering from severe back and abdominal pain.

The coroner ruled had the grandfather been given a leaflet, which he was meant to be given, which explained to go back to hospital if he experienced strong abdominal pains, it was likely he would have gone to hospital sooner. 

This was further complicated by doctors at the hospital asking the couple to call 999 for an ambulance to take them back to Eastbourne, which caused   disagreement with South East Ambulance Service (SECAmb) paramedics, who were told it was not procedure. 

Mr Tucker died one day later at Royal Sussex County Hospital accident and emergency after his blood pressure dropped and he slipped into septic shock.

Following the inquest the coroner has written a report making  recommendations to East Sussex Healthcare NHS Trust, who run Eastbourne District General, to prevent future deaths. The trust must reply within 56 days to say what action it plans to take.

An East Sussex Healthcare NHS Trust spokesman said: “We would like to offer our condolences to the family and friends of Barry Tucker.  

"We work hard to make sure that every patient receives the highest quality care, and we recognise that some aspects of Mr Tucker’s discharge from hospital and our record keeping fell short of this standard.

"We would like to offer our sincere apologies to Mr Tucker’s family and friends. We fully accept the coroner’s concluding comments and we will reinforce our current guidelines so that a similar situation is not repeated.

“This case has been reviewed as part of an internal investigation and it is part of an ongoing complaint. We will be in contact with Mr Tucker’s family and would be happy to meet them should they have any additional concerns.”

A South East Coast Ambulance Service (SECAmb) spokesman said:

“Our thoughts are with Mr Tucker’s family at this difficult time. We provided evidence in court and have taken careful note of the coroners findings and conclusions.

"We have carried out our own investigation into the family’s concerns and are sorry for any distress caused. We will be reporting back to them directly.”