Highland capital hospital to blame for former Marine's death
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THE region’s biggest hospital was to blame for the death of a Royal Marine veteran who died less than two hours after being told he was fit to go home.
A health watchdog has upheld a complaint against Inverness’s Raigmore Hospital lodged by the family of 70-year-old Bob Chalmers.
Mr Chalmers was recovering from a routine knee replacement operation when he collapsed and died in a hospital shower after a doctor had declared him fit to go home.
The grandfather-of-five from Westhill, Inverness worked as a prison officer after leaving the Marines and then as a social worker for Highland Council.
Following his retirement he went to work in the tax office at Riverside House. Mr Chalmers, who died in July 2018, was married to Sandra and they had two daughters.
His wife was preparing to collect him from hospital – only to discover that he had passed away.
One of his daughters, herself a GP in Aberdeenshire, said the family “thought long and hard” before they complained.
The daughter, who did not want her name published, said that in an earlier complaint, NHS Highland had disagreed with the post mortem and the authority did not plan to do anything to change its procedures.
“We, as a family, wanted to make sure systems were in place in NHS Highland so that no-one else had to go through anything similar,” she said.
“My dad was generally fit and healthy. He was a cheerful man, who would chat to anyone. Lots of people in Inverness knew and loved him.”
She went on: “What is clear is that the hospital staff failed to take into account raised indicators on his post-operative blood tests, the fact he was sick twice, had a spike in his temperature, or that he had not been passing urine. They did not seem to take any notice of the signs.
“The registrar discharged dad at 9.30am and said he was fit for home. My mum was expecting to drive to Raigmore to take him home. At 11.20am he collapsed and died in the hospital shower. Staff tried to resuscitate him, and couldn’t.”
A report into Mr Chalmers’ death by the Scottish Public Service Ombudsman (SPSO) detailed the facts.
It said: “On July 11, 2018, Mr Chalmers underwent an uncomplicated left total knee replacement. At 5pm, on July 12, 2018, a junior doctor noted that his blood test results showed a slight acute kidney injury (AKI).”
AKI is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days.
The report continued: “At 7.25pm nursing staff noted that Mr Chalmers had a low blood pressure reading and oral fluids were encouraged. At 11.30pm, it was noted that he had two episodes of vomiting earlier at 9.40pm.
“On July 13, 2018, at 9.30am he was reviewed by a registrar, and was deemed medically fit for discharge. At 11:20am he was found collapsed in the shower room. Cardiopulmonary resuscitation (CPR) was undertaken without success and he died shortly thereafter.”
A post-mortem examination was carried out which found a paralytic ileus of the bowel, a lack of movement somewhere in the intestines that leads to a build-up and potential blockage.
A SPSO spokeswoman said: “We found that NHS Highland board failed to provide a patient with reasonable care and treatment following elective knee surgery.
“The patient died suddenly from causes unrelated to the knee injury after the surgery and we considered that their symptoms prior to discharge were not appropriately acted on.
“Had they been, there is a possibility that other specialists could have been called in to assess and assist. We also noted that not all recognised risks of the surgery were covered sufficiently with the patient at their consultation.”
NHS Highland’s chief executive Paul Hawkins has apologised to the family.
He said: “We apologise for the failings shown in the care and treatment provided and I have personally written to the family offering our sincere apologies.
“We fully accept the findings of the report and it will be shared with all staff and senior managers involved to ensure that we learn from this. This learning will include NHS Highland reviewing its own investigation into this complaint to understand why these failings were not identified through our own processes. The family will be kept up to date on this process.”
