Coroner says further hospital weekend deaths 'possible'

Cheltenham General Hospital
Image caption Amos died following surgery in May 2016

Further deaths could occur at hospitals unless changes are made to the way patients are cared for at nights during weekends, a coroner has said.

An inquest heard Steven Amos died after surgery in Gloucestershire in 2016.

His condition deteriorated over a weekend and he was not seen by a senior doctor until the Monday morning.

Gloucestershire Hospitals NHS Foundation Trust said it was "confident" it had processes in place to "effectively escalate concerns".

An inquest in March heard Mr Amos, 57, from Cheltenham died in May 2016, seven days after having a gastrectomy reconstruction.

His condition deteriorated at 01:00 BST on Monday 16 May, and he was seen by a junior doctor at 03:15 BST.

A senior doctor did not examine him until 08:00 BST.

He underwent an emergency operation at 14:00 BST but died the following evening.

Following the inquest Gloucestershire coroner Katy Skerrett wrote to the trust, which runs Cheltenham General and Gloucestershire Royal hospitals.

Image caption Gloucestershire coroner Katy Skerrett said there is was "a risk that future deaths will occur unless action is taken"

In the letter, which has been seen by the BBC, Ms Skerrett said she was "concerned whether there is appropriate escalation of care given to a patient who acutely deteriorates during the night shifts over the weekend period."

She said: "It is likely that if Steven had been taken to theatre sooner... his chances of survival following the emergency operation would have been increased.

"In my opinion there is a risk that future deaths will occur unless action is taken."

The trust's chief executive, Deborah Lee, said: "Our hospitals have robust processes in place for investigating incidents that give rise to concern, and where standards fall short we are committed to making any changes in practice required to help us improve care for future patients.

"We continue to be vigilant about quality of care, with a low threshold for investigating concerns.

"We have provided assurance to the coroner, Ms Skerrett, that we are confident we have processes in place to ensure our junior clinicians are able to effectively escalate concerns about patients who deteriorate during the night.

"We use an established pathway of escalating clinical concerns that is considered standard practice and is used routinely to ensure patients receive the appropriate level of care, day or night.

"Ensuring our patients receive safe, effective, high quality care remains our top priority."

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