Coroner finds failures of basic medical care caused death of Surrey woman

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Enable Law has supported Mrs Manjula Sharma’s family in proving that unacceptable clinical care was provided to her by St Peter’s Hospital in Chertsey, Surrey. 

The much-loved mother in her mid-sixties died from a cardiac arrest on 24 January 2021 caused by mismanagement of a condition called hypokalaemia and missed opportunities to diagnose an obstruction of her bowel.

St Peter’s Hospital has undertaken a detailed investigation into what happened in Mrs Sharma’s case.

As part of that investigation a report, conducted by an independent surgeon, concluded that it was inappropriate to discharge Mrs Sharma home on 24 December 2020 and had appropriate actions been taken, she would have undergone surgery for her condition of bowel obstruction and survived.

At the Coroner’s inquest, at Woking Coroner’s Court on 25 May 2022, HM Assistant Coroner for Surrey, Ms Karen Henderson, was satisfied that there were multiple occasions of unsatisfactory care throughout Mrs Sharma’s inpatient admissions. The Coroner concluded that Mrs Sharma’s death was contributed to by neglect.

John White, Partner at Enable Law, who represented the family of Manjula Sharma at the inquest said: “This hearing revealed striking failures by St Peter’s Hospital in the care that was provided to Mrs Sharma. It is a tragedy that so many opportunities to save her life were missed.

“Mrs Sharma’s family have suffered greatly, and this outcome is a significant moment for the family. Situations like the one experienced by Mrs Sharma and her family are harrowing and I am proud to have played a role in helping her family achieve justice and peace-of-mind that their concerns have been heard. The family hope that lessons will be learned from the circumstances of Mrs Sharma’s death to save the lives of others.”

Mrs Sharma’s family will now be bringing a civil action in negligence to hold the hospital further to account for their responsibility for the very sad loss of their loved one.

Mrs Sharma visited St Peter’s Hospital four times between 31 October 2020 and 18 December 2020 to complain of pain in her stomach. During each of these visits she was seen by medical staff and discharged with no diagnosis.

She returned to the hospital on 19 January 2021 suffering from weight loss, vomiting, weakness, an inability to walk and continuing stomach pain. She was unable to eat and needed to have her nutrition given through intravenous fluids and a feeding tube that ran from her nose to her stomach. On 24 January 2021 Mrs Sharma suffered a cardiac arrest and, despite being resuscitated once, was declared dead.

It was discovered by the post-mortem examination that Mrs Sharma had an undiagnosed obstruction in her small bowel which should have received surgical treatment. Furthermore, the cardiac arrest was most likely caused by a low potassium level, known as hypokalaemia, because during the final admission to hospital she had not received the correct fluid support, monitoring and nutrition.

Another crucial aspect to the failures in the care by St Peter’s Hospital was during the fourth admission, on 18 December 2020, when the radiologist did not report correctly on the signs of the small bowel obstruction on Mrs Sharma’s CT scan. If this had been correctly reported it would have led to a diagnosis. There was no bedside consultant review and a lack of input from senior staff, and no laparoscopy was undertaken that would also have diagnosed the cause of her illness.

Mrs Sharma’s family believe poor communication with the hospital contributed to her death, both due to the language barrier between Mrs Sharma and the staff at the hospital, and by not engaging with the wider family who could have helped to provide additional information.

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