Woman's death in hospital after surgery went wrong 'could not be reasonably avoided'

The family of Sarah Aaron, who died at Royal Shrewsbury Hospital on June 27, 2022 just days after elective weight loss surgery, took the chance to quiz medics with their concerns about the 47-year-old's care at the resumed inquest into her death.

John Ellery, Senior Shropshire & Telford Coroner had heard that there had been "tensions or conflict" between the findings of a hospital investigation and the evidence heard at Tuesday's inquest.

But he said he would deal with that by giving the hospital a chance to consider if it needed to update its report and then let the family see the results.

Mr Ellery, sitting at the Coroner's Court at Shirehall, concluded that Mrs Aaron, a personal assistant from Horsehay, died of complication of a second surgical procedure following a complication of a first.

The inquest heard that Shrewsbury-born Mrs Aaron underwent elective gastric surgery on June 21 and was due to be discharged home the next day, following what is normally a "relatively low-risk" procedure.

However, sadly Mrs Aaron started to feel unwell and had two further surgical procedures on June 24 and 27 by which time her her condition had seriously deteriorated.

The inquest heard that the procedure on June 24 was followed by a leak in her bowel which occurred likely late on the 26th, and she began to become septic from this point. She suffered a cardiac arrest at 5.10am on the 27th.

By that time, the inquest heard that her condition was irretrievable, with death being confirmed at 9.50pm that night.

Sarah's husband, David Aaron, took the opportunity to ask a series questions of medical staff about the treatment his wife received, including whether they could have done more to treat sepsis.

He focused on the crucial hours between 10pm on June 26 and 5am the next day, after when the family agreed to the heartbreaking decision to turn off her life support after her condition became irretrievable.

Mr Ellery had previously heard that there were "inaccuracies" in hospital notes which had claimed that there was no sepsis involved. This had raised doubts about whether her "rapid deterioration" was spotted and acted upon.

A post mortem had concluded that Mrs Aaron's medical cause of death had been multi organ failure, with contributing factors being bowel obstruction and anastomotic breakdown with peritonitis, elective Roux-en-Y Bypass surgery (on June 21), morbid obesity, obesity related cardiomyopathy, non-alcoholic fatty liver disease, and multiple sclerosis.

Hospital staff passed on their condolences to the families before giving evidence.

Dr Aayush Gupta, hospital registrar at the time, told the inquest that sepsis had been the "main concern" on the night of the 26th.

But he said that taking a blood culture would not have helped because it would take two days to get the results back.

The inquest also heard that that antibiotics in Mrs Aaron's system can mean such blood test results would come back negative.

Dr Gupta said he had "personally reflected" on the circumstances but maintained that "I do not think there was anything else that would have changed the outcome."

Dr Joseph Anku Roberts, an on call senior house officer in the intensive care unit, said he believed that Mrs Aaron "had all the treatment you would normally give to a sepsis patient".

Mr Aaron praised the team for their efforts to resuscitate his wife.

Mr George Kirby, a consultant surgeon, stood by a statement he made at an earlier stage of the inquest that "earlier intervention would not have made a difference". And he added that it was "unlikely" that another operation would have made a difference.

Mr Aaron said he and his family wanted to give his wife the "best possible chance" and had been concerned that there had been "potentially missed opportunities".

Mr Kirby said that treatment decisions are "an opinion" but he said that nurses had escalated Mrs Aaron's condition "immediately" .

The coroner asked Mr Kirby whether opportunities could have been missed to which he replied: "In perfect hindsight, potentially so. I do not think another operation could have changed that."

Mr Ellery said the family's "wish and belief for the best possible outcome" had "directed the facts of the inquest and the evidence called".

He said he had to base his conclusion on the evidence, facts and the "balance of probabilities".

The procedure Mrs Aaron had received had with it a mortality risk of "less than one per cent" but Mr Ellery said for Mrs Aaron that had in effect been 100 per cent.

Mr Ellery said an operation on June 21 had had no apparent complications but she had two further operations on the 24th and 27th, with the operation on the 24th being the "critical event" that lead to a bowel obstruction.

"Without hindsight could Sarah's life have been saved?" he asked. "I have to reach conclusions on the evidence."

That evidence had been provided by seven doctors and a nurse, and Mr Ellery said that "she did receive appropriate treatment and her death could not be reasonably avoided",

Mr Ellery concluded that Mrs Aaron had died from complication of surgery, i.e. the second surgery following a complication of the first.

He added that "at very least it has given the family the chance to ask questions".

Mr Ellery added that "tensions or conflict" between a Serious Incident report compiled by the hospital trust and what he had heard at the inquest would be passed back to the investigator who would consider if an update is required.

The SI report said that she had not been screened for sepsis, but a note added after the fact in the medical records contradicted that.

Mr Ellery commended Mr Aaron for the "professional and courteous" way that he had pursued his concerns.