Bristol Coroner returns neglect verdict after man died following open-heart surgery

Freeths acting on behalf of victim's family, hopes the findings will be a lesson learned to avoid future tragedy.

National law firm Freeths has today called for change in patient records following neglect verdict from coroner.The inquest into the death of 74-year-old Donald Gore, a retired Bristol engineer, heard of failings of medical care and heart valve operations after a 5-day hearing concluded with a verdict of natural causes contributed to by neglect. This followed the latest inquest following a series of deaths in the outbreak of cases of mycobacterium chimaera from infected LivaNova heater cooler units used in heart valve operations.Avon Assistant Coroner Dr Simon Fox QC found that Mr Gore died of mycobacterium chimaera contracted from the aerosol produced from an infected LivaNova heater cooler unit used during heart valve surgery at Bristol Royal Infirmary on 16th November 2016.Mr Gore became ill in November 2017 with classic symptoms of mycobacterium chimaera but although the worldwide problem was first identified to Public Health England in 2014 there was a delay in doctors diagnosing the infection in Mr Gore until June 2019 by which time it had spread throughout his body, and it was too late to begin treatment. He died on 24th August 2019.The coroner ruled that Mr Gore's death had been contributed to by neglect. He found that in March 2017 the hospital did not send Mr Gore the standard letter to patients advising him of the risk; the GP to whom he first presented with symptoms did not read the alert sent by Public Health England to doctors or refer to the risk in referring Mr Gore to hospital; the hospital doctors, in particular those specialising in infectious disease, microbiology and cardiology were unaware of the risk, and when they did order tests they were delayed. During the 21 months of delay, Mr Gore was misdiagnosed with sarcoidosis for which he was treated with long term steroids which may have accelerated his infection or made it more severe.The inquest heard evidence from doctors, Public Health England and LivaNova, the manufacturers of the infected heater cooler unit.Commenting after the ruling the family's solicitor, Paul Balen, Clinical Negligence Consultant at Freeths, said: “Mr Gore's death is one of 33 known fatalities out of 49 known cases reported in the UK. Coroners are being repeatedly told that doctors were unaware of this rare illness. If nothing else this inquest demonstrates the need for all patients who had undergone open heart surgery after 2005 at hospitals using LivaNova heater cooler units having a warning alert placed on their patient records so doctors are aware of the issue. If further lives can be saved as a result the exercise would be worthwhile.”


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