A coroner found Barry Loxston was left in his own faeces for hours and handled poorly by nurses while he had a broken collarbone
A 67-year-old man died in a South London hospital after surgeons carried out a kidney transplant when he wasn’t fit to undergo one.
Barry Loxston, 67, died at St George’s Hospital, in Tooting, on July 30, 2023, after developing complications from a kidney transplant.
A recent inquest found Mr Loxston died as a result of “serious failures” to recognise he was unfit for a kidney transplant, which he underwent on July 8. He developed complications after the operation and went into cardiac arrest on July 30. He died shortly afterwards.
Fiona Wilcox, Senior Coroner for Inner West London, issued a Prevention of Future Deaths report to St George’s University Hospitals NHS Foundation Trust after the inquest, where she raised concerns about the care Mr Loxston received. She said being left lying in his own faeces more than once and poor handling by nurses had a major impact on his mental health.
One staff member described him as “being low in mood and to simply have had enough” after the surgery.
Mr Loxston had dialysis-dependent kidney failure caused by long-term use of indomethacin for an inflammatory disease. He was placed on the transplant waiting list by St Helier Hospital, in Carshalton, and was admitted to St George’s for the surgery on July 8, 2023.
Ms Wilcox said Mr Loxston had not been removed from the transplant waiting list, despite suffering from chronic diarrhoea and falling albumin – a protein found in plasma – in the final months of his life.
She found the nephrology team at St Helier and the transplant team at St George’s failed to spot he was unfit for surgery due to his chronic diarrhoea causing malabsorption and low albumin. Although the surgery was initially successful, he developed complications due to low albumin which contributed to circulatory failure, electrolyte imbalance and delayed graft function.
The coroner said Mr Loxston fell and broke his collarbone when he arrived at hospital and his family reported multiple instances where nurses did not handle him properly afterwards, which caused him significant pain.
She found he was left lying in his own faeces more than once after staff failed to bring him a portable toilet, including one instance where he was left in this state for nearly five hours.
The report said: “There was no doubt that the nursing matters outlined above had a significant detrimental effect on his mental wellbeing and he was described by the nephrologist who cared for him at St George’s in the postoperative period as being low in mood and to simply have had enough.
“Whilst it could not be found that these matters directly caused or contributed to his death, I was satisfied that they possibly did so by affecting his overall wellbeing following serious surgery and its complications.”
Ms Wilcox also found errors in the administration of Mr Loxston’s medication and multiple times when his medicine was discovered on the bed or floor as he had been left to take it unsupervised. She said it was only a matter of speculation whether this contributed to his death, but that a post-mortem of the donated kidney found signs of delayed graft function – essentially meaning the kidney didn’t work straight away – and rejection of the organ by his body.
She ruled Mr Loxston’s death was “preventable and predictable” as all witnesses at the inquest agreed he should not have had surgery with such a low level of albumin, due to post-operative complication risk, especially as the cause of it was unexplained.
A St George’s University Hospitals NHS Foundation Trust spokesperson said: “We are deeply sorry that Mr Loxston didn’t receive the high level of care he would have expected from us, and we offer our sincere apologies and condolences to his family.
“We carried out an investigation to learn from this and have since made important improvements to avoid this happening again – this includes reviewing patients on the transplant list to identify any potential issues that may affect their suitability for transplantation.”
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