Coroner's concern at out-of-hours doctor support services at Kingston Hospital

Bruce Paterson died from a severe stomach haemorrhage after a delay in receiving blood for transfusion and a lack of doctors to perform an endoscopy, South West London Coroner’s Court heard.

The inquest heard junior doctors tried to stabilise the Teddington pensioner and frantically rang gastrologists for help but could not get through.

Mr Paterson was admitted to Kingston Hospital after he suffered a stroke on December 17, last year.

He had a temporary nasal tube inserted and remained in hospital until January 21 this year, when a permanent feeding tube was inserted into his stomach and caused the stomach haemorrhage.

At the inquest on Tuesday, November 20, Coroner Dr Sean Cummings raised concerns over the hospital’s ad-hoc arrangement with the bleed support service, given the risk of haemorrhages after tube insertions.

He said: “There is a question to whether it can be done safely if they have known side effects that can result in death because those side effects can’t be dealt with in the hospital.”

The hospital has a Monday to Friday 9am to 5pm support service but doctors work on an ad-hoc basis in the evenings and at weekends.

Dr LiLian Choy, a consultant physician who was responsible for Mr Paterson’s medical care, said it was not unusual for a hospital not to have a 24-hour endoscopy or gastrology service.

She said: “A lot of people have GI bleeds and we are able to stabilise them. In an ideal world we would have a 24 hour on-call service.”

Dr Tim Heyman, an on-call doctor at Kingston Hospital, said the ad-hoc arrangement had worked well for 16 years and was a system in place at 60 per cent of NHS trusts.

He said it was likely the outcome would have been the same for Mr Paterson even if he had been given an endoscopy, as the procedure puts a huge strain on patients.

He said: “Do I think we can continue to do this without a formalised GI bleed rota?

“Yes, I do, because I think that such complications are extremely rare.”

Dr Cummings concluded Mr Paterson died of “an enormous and catastrophic haemorrhage” and said he would write to the hospital about his concerns.

A spokesman for Kingston Hospital NHS Trust said: “We would like to offer our condolences to Mr Paterson’s family for their sad and tragic loss.

“Following Mr Paterson’s death a full investigation was carried out by the hospital, the results of which, showed that having an endoscopy could not have prevented his death.

“However, the investigation into his death highlighted some improvements which could be made to our out of hours arrangement. We are currently in the final stages of implementing these changes.”