Series of Errors by Isle of Wight NHS Trust Contributed to Death of ‘Active’ Dad-of-Two After Heart Surgery

An inquest on 6th and 7th July 2022 into the 2019 death of Mr Steven Hasler, 35, has found that failings and missed opportunities by Isle of Wight NHS Trust significantly contributed to the death of the father-of-two from Ryde.

Mr Hasler had undergone open-heart surgery at Southampton General Hospital’s specialist cardiac surgery unit to replace a defective aortic valve. While the operation was successful, Steven later developed a severe infection of his chest wound.

Upon seeking medical help at St Mary’s Emergency Department, Mr Hasler was ‘badly let down by the doctors’ as his condition was overlooked, and a series of failings meant he did not receive the specialist care he needed. Steven died less than 3 months after his operation in what the inquest found was a preventable death.

Open-Heart Surgery to ‘Get Back on His Feet’

Mr Hasler had a congenital heart valve defect that never significantly impacted his quality of life until recently, necessitating an operation in November 2018.

According to Mr Hasler’s family:

 “We were all aware of Steve’s underlying heart condition since he was born, but he never let it hold him back and, for most of his life, Steve was the fittest and strongest person we knew. He was the comedian of five siblings and made everyone around him laugh.

When he started to get some symptoms from his heart condition and was told he needed open-heart surgery in 2018, Steve was very nervous, but he knew it was important to go ahead with the operation to get him back on his feet so that he could continue being an active Dad to his two kids, who meant the absolute world to him.”

Mr Hasler underwent successful open-heart surgery at Southampton General Hospital on 22nd November 2018. But upon returning to his home in Ryde, Isle of Wight, he developed post-surgical complications. The chest wound was not healing as it should, and there were concerning amounts of pus and blood.

Mr Hasler attended the Emergency Department at St Mary’s Hospital on 7th December 2018, seeking medical advice for his concerns. After consultations and blood tests, it was determined that he had developed a significant bacterial infection.

The inquest heard that Mr Hasler’s CRP level (a marker of inflammation) on 7th December was 350mg/L, 70 times higher than the 5 mg/L levels in a typical healthy person. The blood tests thus revealed that he had developed a serious infection.

‘Incompetent Handovers’

Given Mr Hasler’s recent operation, specialist care by a cardiothoracic surgical team was required to manage his infection. The senior general surgeon who saw him recognized this and discharged Steven after administering intravenous and oral antibiotics, intending to contact the cardiac surgeons at Southampton General later.

However, a series of ‘incompetent handovers’ meant that the specialists at Southampton General were never aware of Mr Hasler’s infection.

In an error of judgement, the senior general surgeon at St Mary’s asked the day team to handle communication with Southampton General because it was late. He left the instruction on a handover sheet. Still, his colleagues on the day shift never made the call—and the senior general surgeon did not follow up.

Another opportunity to rectify the mistakes in Mr Hasler’s care was missed when a “woefully inadequate” Discharge Summary sent to his GP from the A&E attendance left out information on his elevated CRP levels and the intention to seek specialist advice from the cardiothoracic team at Southampton General.

A post-mortem examination concluded that Steven succumbed to widespread sepsis on 14th February 2019 due to an endocarditis periaortic leak, which developed following his heart valve replacement.

Mr Hasler’s family said:

We were relieved that the surgery seemed to go well, but Steve never got the chance to look after his children again because his chest wound struggled to heal and the infection was not properly treated…..His death at such a young age came as a huge shock to the whole family and we feel he was badly let down by the doctors he saw at St Mary’s Hospital on 7th December 2018.”

Measure to Improve Medical Services

Following the inquest, Coroner Caroline Sumeray said there had been:

 “..incomplete handovers of his medical care at St Mary’s hospital and a failure to recognise the seriousness of his condition. This significantly contributed to his death…..Had there been an effective and prompt notification of his condition to Southampton General or a comprehensive discharge summary alerting his GP to the need for onward referral, on the balance of probabilities, he would have received appropriate care and treatment which may have saved his life.”

Speaking to Mrs Sumeray at the hearing, the Trust highlighted measures they had put in place to improve their services—including the handover of information, handling post-surgical chest wound infections, and detailing Discharge Summaries.

After a long fight for answers over Mr Hasler’s death, his family said:

Over three years later, we are pleased that the coroner and the Trust have recognised the errors which contributed to his death and, whilst it will not bring him back, we are glad that as a result, it seems that measures are being taken to improve medical services for other patients on the island.”

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