A lack of communication between doctors at Barnet Hospital led to delays in treating a patient who died after suffering internal bleeding, an inquest heard.
Wheelchair-bound Koula Christou, 53, of Park Road, New Barnet, bled from an ulcer in her stomach area prior to her death on the night of January 27 last year.
The inquest, at North London Coroner’s Court, heard there had been delays in referring her for an endoscopy and that she had needed interventional radiology that morning.
Medical negligence expert, JW Rodney Peyton OBE, a former general surgeon, said personal discussions should have taken place between doctors in order to put her on the emergency list for theatre.
He said: “The list is for surgeons of the day to be able to fit things in if they have to, and hospitals are set up to deal with those consequences.”
He said she would have been “on thin ice” and that there had been “a domino effect” of problems, but that there was a lack of communication.
He said: “The number one thing that should have happened here is that all the people of senior level who were involved in the management of this patient should have got together and said what’s going on?”
He added: “We’re looking at a situation where a very ill patient has been waiting a considerable amount of time and everyone of them should have known about it.”
HM senior coroner Andrew Walker asked: “Are we looking at a system failure rather than an individual error?” to which Mr Peyton replied “Yes.”
George Hugh-Jones QC, acting for the Royal Free London NHS Foundation Trust, said it wouldn’t have been easy to “interpose” a patient on the emergency list.
He said the case had “complexity” and had been “difficult to read” and asked Mr Peyton “if the judgement calls could be viewed in a lesser light?”
He replied: “No-one sets out to hurt anyone, but here you have experienced clinicians whose training prepares them to deal with complex patients.”
During a break in proceedings on Friday (February 17), Miss Christou’s family paid tribute to her, stating that she had been a fiercely independent wheelchair user and had worked as an insurance adviser at Harringey Council.
She gave up work five years ago to care for her elderly mum who she lived with, but who had had to go into a care home since her daughter’s death.
The inquest, at Wood Street, High Barnet, continues this week.