Coroner's report into death of Washington woman following gastric surgery highlights "woeful" aftercare experienced at private hospital

Whilst the coroner could not reach a definitive conclusion as to the chain of events which led to Nicola Fisher’s death on January 11, 2024, she did identify that “woeful” checks or recording of checks on Nicola before her discharge has made it difficult for her to reach a definitive conclusion regarding her passing.

The hospital have offered their condolences to the family after Mrs Fisher’s passing and said they have carried out a “thorough investigation”.

However, in the report of the coroner’s findings shown to the Echo, she did say: “What is clear is the surgery Nicola had on June 12 has been the precipitating event leading to a very difficult journey for Nicola and her family that has ultimately resulted in her death.”

Nicola Fisher was 54 when she passed away from multi-organ failure. She had gone into the Spire Washington Hospital on June 11 for a surgical procedure to fit a gastric sleeve to help Nicola with her weight loss. The procedure involved the removal up to 85 per cent of her stomach to restrict Nicola’s appetite and food consumption.

The successful business woman, who was managing director of French Beauty Expert, had a gastric band fitted in 2009 but it had not delivered the results she was hoping for.

The surgery, on June 12, 2023, had the added complication of the removal of the existing gastric band – but Nicola was deemed fit to be discharged on the early evening of June 13.

However, after experiencing vomiting and shortness of breath the following day, Nicola ended up being taken to Sunderland Royal Hospital by ambulance where she underwent surgery after developing a severe abdominal infection. The surgeon identified evidence of a leak which he attempted to close and left a drain in, expecting the leak to continue as it did.

The coroner’s report findings identified the medical situation as “challenging”.

Further surgery took place at the hospital on August 18, 2023. Again the surgery was described in the report as challenging, but appeared successful and Nicola was well enough to be discharged on August 24.

However, in November another leak was found. This was drained on November 28 and attempts were then made to “build her up nutritionally”.

Sadly, Nicola’s condition deteriorated due to another infection and she passed away on January 11, 2024 in Sunderland Royal Hospital.

The coroner’s focus during the inquest was on the initial surgery at Spire Washington Hospital, Nicola’s aftercare, and whether any leak should have been identified before she was discharged from the hospital.

The coroner’s report stated the surgeon had visually checked the area and “no leak was detected” and the coroner agreed in her report that being discharged the following day “would be appropriate in the absence of any contra indications”.

However, representatives from Slater and Gordon Lawyers, who were representing Nicola’s family at the inquest, raised a number of concerns about her aftercare which they argued failed to detect the leak.

One of the main issues identified was not doing a leak test.

In her report the coroner stated: “No leak test was done after the conclusion of the procedure. This would be done at Sunderland Royal Hospital, but not at other trusts.”

At the inquest into her death, it was revealed that appropriate observations were either not done or recorded before her discharge, medications were not given as expected, and Nicola’s pre-discharge blood test results were also not checked prior.

The coroner stated in her report: “There are a number of matters that cause concern about Nicola’s experience at Spire on June 13. Medications were not given as expected and prescribed fluids were not given. There may well have been a clinical reason why the administration of fluid was not given but this was not documented.

“I have nothing to assure me that observations were done on Nicola after 10am on June 13 and indeed there is very little documented about Nicola in for example the progress and evaluation documentation that assists.

“The blood test results were not considered before discharge. Although a discharge summary was completed indicating a score of 0, I do not know if this means that an assessment was done or if it was merely taken from observations done earlier that day.”

The coroner highlighted how the lack of documented observations “hampered me in having a clear understanding of Nicola’s condition at the time of discharge so as to enable me to make findings one way or another as to the appropriateness of Nicola’s discharge”.

She added: “This is woeful. It also means Nicola’s family do not have the assurance of knowing that Nicola’s care after 10am on June 13 was as it should have been.”

On the ultimate cause of the leak which led to complications, the coroner identified two “equally plausible” explanations; one, the leak was as a direct result of something done during surgery and another, the leak was an indirect consequence of the surgery and it may be that the leak occurred sometime after the operation.

On the first possible reason the coroner said :”In this situation I would be of the mind that given that Nicola had had direct fluid and pureed food prior to her discharge, that this would most likely have begun to have an impact on her before discharge and that this is something that would have been apparent from observations.”

On the second scenario she added: “I note the leak was not apparent to the surgeon during the procedure and in this situation then I would be of the mind that this would not necessarily be apparent prior to discharge.”

Ultimately the coroner could not make a definitive decision.

She said: “I must base findings on evidence and I cannot make assumptions. I therefore find myself in the position that I cannot make a finding one way or another on this point and I am sorry that I am not able to give Nicola’s family clarity on this aspect of my investigation.”

The coroner was, however, damning in her criticism of the aftercare Nicola experienced at Washington Spire Hospital and the recording and documentation of information.

She said: “I rather suspect there is a perception in the general public that paying for treatment at a private hospital results in a quicker and better standard of care. As indicated, this was not the case for Nicola, certainly after 10am on June 13 when the basics were either not done or not documented.”

Following the inquest, Nicola’s husband, Peter Fisher said: “I know Nicola would never have gone ahead with this procedure, particularly if she had any idea the aftercare would be so woeful, as it was quite rightly described, and the most basic of checks would not be performed prior to her discharge.

“Nicola and I were so happy together. She was so vibrant and such a lovely person. I miss her dreadfully every day.”

Slater and Gordon lawyer, John Lowther, who was representing the family at the inquest, added: “The loss of Nicola is felt acutely by Peter, who had to witness his wife’s slow and painful decline over the course of several months after what she hoped would be life-enhancing weight loss surgery at Spire Washington Hospital.

“The inquest has led to the identification of a series of basic failures on the part of Spire Washington Hospital, which may have presented missed opportunities to avoid her suffering and death.

“We continue to fight for Peter and will support him in finding answers.”

The inquest did acknowledge that a leak following surgery of this nature is “a recognised risk” and that Nicola had signed the necessary consent form and had made an informed decision to go ahead with the surgery.

The medical cause of death listed on the coroner’s record of inquest is multi-organ failure, but she references complications of bariatric surgery and obesity.

We asked Spire Washington Hospital for a response to the concerns raised during the inquest.

A spokesperson said: “The safety of all our patients is our highest priority, and we offer our very sincere condolences to Mrs Fisher’s family for their loss.

“Spire carried out a thorough investigation into Mrs Fisher’s care at Spire Washington, at the time the initial complication arose, and completed an action plan to strengthen its processes in relation to the issues identified.”