A north-east London hospital trust has apologised following a string of failures that led to the death of a woman 10 days after a kidney biopsy.
Beloved mother-of-five Sultana Razia Choudhury, 60, suffered a complication during the procedure in December, which resulted in a catastrophic internal bleed.
A coroner has concluded that gross failings in her care amount to neglect, which caused her death on December 17.
Barts Health NHS Trust, which runs the hospital, has apologised to Mrs Coudhury’s family and said changes will be made.
Mrs Choudhury was a mother-of-five with 12 grandchildren, who filled her family home with “love and care” and “nurtured those around her”, an inquest at East London Coroners’ Court heard on Thursday. Originally from Bangladesh, she lived in Walthamstow with her husband of 50 years.
She volunteered to undergo the kidney biopsy as part of a clinical study into the link between diabetes and renal issues.
“This absolutely typifies her decision making,” coroner Graeme Irvine told the inquest. “She wanted to help people.”
Mrs Choudhury was discharged after the procedure at the Royal London Hospital on December 7, but a week later attended A&E at Whipps Cross Hospital in “excrutiating” pain.
On admission she was diagnosed with a kidney infection, and tests led medics to believe she had developed sepsis.
Scans failed to reveal to doctors that she was suffering a “profound bleed” post-surgery.
But the coroner said a “problematic blood result” should have prompted medics to investigate further.
Instead, Mrs Choudhury was instead treated for a bacterial infection, and was prescribed anticoagulant enoxaparin, which reduces the body’s clotting system.
“She shouldn’t have received anticoagulants,” said Mr Irvine. “If a patient is actively bleeding an oxyparin is impairing the body’s ability to stop that bleed.”
Over the next three days, Mrs Choudhury deteriorated before suffering a cardiac arrest and dying on December 17.
Mr Irvine said there were “a number of missed opportunities” to take a closer look at Mrs Choudhury’s symptoms, which “could have saved or prolonged her life”.
“There was a lack of focus or awareness about what the likely causes of her presentation were,” he said.
He said the fact she had recently undergone an operation should have been considered.
“A moment’s sober reflection, having considered the history of a recent biopsy, really ought to have resulted in further investigation as to whether Mrs Choudhury was suffering a significant bleed,” he said.
A serious incident (SI) investigation report was carried out by Barts Trust following Mrs Choudhury’s death.
The coroner described the results as “damning”, and identified several areas of concern regarding Mrs Choudhury’s care.
“All of this points to poor level of care,” he said.
Recording a conclusion of ‘accident contributed to by neglect’, Mr Irvine said he plans to make a rare ‘prevention of future deaths’ report, which he will send to the Department for Health and Social Care.
“I still do have a real concern that there are potential problems in the trust which could result in an event like this happening again,” he said.
He also called for the trust to consider holding individual medics responsible for mistreating Mrs Choudhury.
“At some stage people have to take responsibility for their own decision making,” he said.
“The trust has not chosen to adopt an approach about individual actions, and that’s a point of concern for me.
“I’ve got the utmost sympathy with the NHS. It seems to me they’re under-resourced - they’re doing more with less. It’s very easy to pick on individuals, but sometimes personal responsibility needs to be part and parcel of a remedial approach by the trust.”
Mrs Choudhury’s family said in a statement: “The loss of our mum, who was known as a ‘mum’ to everyone, has left a huge hole in our family. We are grateful to the coroner that her death was thoroughly looked into and the many problems in her care identified.
“It’s ironic that she did this biopsy as she was convinced that this would contribute to clinical research, and it would be impactful in helping improve the treatment and wellbeing of others.
“This is the sole reason why she did it; she had no other reason to. Ultimately, this decision is what lead to her death. She passed away just as she lived - trying to help others.”
Frankie Rhodes, solicitor at law firm Leigh Day, who provided counsel for the family, added: “The coroner’s finding of neglect, along with issuing a Prevention of Future Deaths report, reinforces the legitimate concerns Sultana’s family had with their mother’s care and goes some way towards reassuring them that these mistakes will not be repeated.
“It was shocking to hear staff at the defendant trust admit to issues with diagnostic overshadowing, confirmation bias, medication errors and the failure to do a simple CT scan.
“There were multiple opportunities for staff at the trust to have identified that Sultana was bleeding from her kidney and to have treated her injury accordingly.
“It is even more worrying to hear that the coroner has identified a pattern of similar mistakes being made and the recommendations for improvement not being implemented within trusts in east London.
“We can only hope that the findings in this inquest act as a vehicle for much needed change.”
A spokesperson for Barts Health NHS Trust, which runs Whipps Cross, said: “We express our deepest sympathies to the family of Ms Choudhury and we apologise that in this instance, the care we provided did not meet the standards we set ourselves.
“We have taken learnings from this case to make sure we maintain these standards and prevent this happening again.”