Row over guidelines after Sutton woman died waiting for surgery transfer

Teresa Dennet was a patient at King's Mill Hospital. She died as a registrar fought to secure an intensive care bed at two other hospitals.
Teresa Dennet was a patient at King's Mill Hospital. She died as a registrar fought to secure an intensive care bed at two other hospitals.

A Sheffield hospital has pointed the finger at Nottingham's QMC over Sutton woman Teresa Dennett's death after a dispute over surgery.

An inquest into the death of Teresa Dennett, 58, said both Queens Medical Centre and Sheffield Teaching Hospital had turned her away as doctors at King's Mill Hospital battled to find her an intensive care bed as she awaited neurosurgery.

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King's Mill stroke victim died while neighbouring trusts refused life-saving treatment

Now bosses at the Sheffield Trust have hit back at claims they did not have a clear protocol in place, stressing they never refused to accept a female patient for an operation, and have instead claimed Nottingham University Hospitals did not follow guidelines.

Dr David Throssell, Medical Director at Sheffield Teaching Hospitals NHS Foundation Trust said: “We were so very sorry to hear of the tragic death of Mrs Dennett and no words are enough to describe how devastated her family must be.

"When contacted by Kings Mill Hospital, our clinician gave advice consistent with clinical guidelines from the Society of British Neurological Surgeons which states that surgery should take place at the nearest appropriate neurosurgical centre (Nottingham) as quickly as possible, regardless of any issue with bed availability.

"If Nottingham had confirmed with us that they could not undertake the surgery, as per the clinical guidelines, we would have operated on Mrs Dennett in Sheffield regardless of bed availability.

"We will be discussing with Nottingham and Kings Mill Hospitals the lessons which need to be learned in respect of the use of the clinical guidelines, so that the chances of this happening again are limited."

Peter Homa, chief executive of Nottingham University Hospitals, said in response: “We extend our condolences to Mrs Dennett’s family and apologise that we were unable to transfer her to our specialist unit immediately to consider surgery. We have agreed with our neurosurgeons that we will accept patients whom they consider would benefit from lifesaving emergency surgery regardless of our ICU or other bed availability, as now required by NHS England who have now adopted the earlier quality statement on the Society of British Neurological Surgeons website. We are working internally and with partner hospitals to minimise the risks to other patients (notably those in intensive care units) from this approach.”

A Freedom of Information request, sent by Teresa's family revealed Sheffield had both surgeons and intensive care beds available, although the hospital insisted they didn't have a 'level 3 neuro-surgery ITU Bed'.

Her daughter, Maryanne Mason, who works at King's Mill, told ITV: "I could see how hard the doctor at Kings Mill was trying to get the surgery. He stood at the nurses station calling hospital after hospital.

"For him then to take us into a room to tell us my mum had deteriorated so much the operation would no longer be possible. I had to go and tell her and have her cry in my arms to hear I couldn't save her."

Inquest issues Preventing Future Death notices to trusts

Mrs Dennett, from Sutton, was admitted to King's Mill on February 6 last year suffering from a rare type of stroke, but scans showed a sudden deterioration requiring neurosurgery to relieve pressure.

After repeated attempts by a registrar at King’s Mill to transfer her first to Nottingham’s Queen’s Medical and later to a hospital in Sheffield failed, staff in Nottingham advised that no intensive care beds were available for Ms Dennett and said King’s Mill staff should continue to observe her condition. Doctors were then told to ask Sheffield Teaching Hospital to take Ms Dennett - but while doctors there were willing, a consultant insisted she should be treated in Nottingham.

In desperation, an on-call stroke doctor was contacted and it was agreed that Ms Dennett should be transferred to Nottingham.

But by then it was too late and Ms Dennett had deteriorated too much for surgery, and died later that morning.

In her report to NHS England chief executive Simon Stevens following an inquest into Ms Dennett’s death, assistant Notts coroner Heidi Connor said: “Crucially, it was clear there was no written protocol in place to set out a clear pathway for referral for emergency neurosurgery.

“The medical registrar at King’s Mill Hospital was left trying to broker a deal with multiple neurosurgery units and valuable time was lost in this process. There is a risk that future deaths will occur unless action is taken”.

She also concluded that if swifter action had been taken, there was every chance that Ms Dennett would have survived.

Sherwood Forest Hospitals Medical Director Dr Andy Haynes said: “This a very sad and tragic case and should never have happened.

“The coroner rightly praised our medical registrar for doing all he could to facilitate a very difficult situation.

“Our actions have not been called into question, however we will of course work collaboratively with other trusts cited by the coroner to improve care for all patients served by the NHS.”

The coroner issued a Preventing Future Death Notice to Nottingham Universities NHS Trust and to Sheffield Teaching Hospital.