Justice for Robert Henderson at last
In October, the Eye campaigned for justice for Robert Henderson, an agricultural officer, who died after substandard care at Treliske Hospital in Cornwall on October 7, 1999. His cousin John, an Emeritus physician at the Ottawa Hospital, has spent a vast amount of time and money trying to get the hospital to acknowledge the serious failures that led to Robert’s death. John meticulously reviewed and analysed Robert’s medical records, which were then thoroughly reviewed by a panel of medico-legal experts (3 university professors and a coroner). Their conclusion was grave negligence. Robert Henderson died shortly after perforating a duodenal ulcer, which may have been caused by his medication and certainly should have been investigated, diagnosed and operated on a lot sooner, given the amount of pain he was in, extreme tenderness on examination and the documented suspicions of a referring GP. John wrote to Lezli Boswell, current Chief Executive of Royal Cornwall Hospital Trust (RCHT) on the fourteenth anniversary of Robert’s death, and the Eye promised to publish the response. (Eye 1350).
‘Thank you for your letter dated October 7, 2013. I have now had the opportunity to review the file of earlier correspondence between you and the Trust since the death of your cousin, Mr Robert Henderson. Firstly I would like to apologise again for the Trust’s historic failure to address your concerns between 1999 and 2009. I believe, however, that you may not have received a copy of a letter sent to your solicitors which was sent to them on 25 November 2009 which sets out the process and findings of the Trust review of the circumstances surrounding Robert’s death. I have enclosed this letter, which clearly sets out that there were a number of elements of the care which the Trust provided to Robert were below the expected standard and that our mortality review committee concluded that there were areas of concern that ‘may have contributed to the patient’s death.’ For the Trust’s failure in the care given to Robert, I apologise unreservedly.’
Robert Henderson’s death has all the elements of a Greek tragedy. He and his wife Marjorie, a plant pathologist, were involved in a car accident on August 30, 1999, which left Mr Henderson with a fractured pelvis and unable to walk. He was given Voltarol for his pain, which is likely to have contributed to his gut perforation, a surgical emergency which was missed until 52 hours after his pain started. Delayed surgery found a perforated duodenal ulcer, and ‘4-6 litres of bile + muck + tablets’ were removed from the abdominal cavity. He was transferred to ITU where his treatment was further complicated by post operative respiratory failure, failed extubation, pneumonia, cardiac arrhythmias, anaemia and MRSA infection at several sites. He had a fatal cardiac arrest on October 7, and the autopsy report submitted to the coroner found ‘a natural cause of death.’
Robert’s wife Marjorie knew he had received substandard care, on one occasion finding him unshaven and unwashed, but she too had been injured in the crash and only felt able to take her concerns to the sister and not his consultant. The denial of this poor care and mistakes in the management of his abdominal pain lasted a decade and when it was finally acknowledged in a letter to the family’s solicitor in 2009, the solicitors, Stevens and Scown, filed the letter and failed to pass it on. Marjorie Henderson has been left in the dark, without an honest explanation of her husband’s death, for 14 years and John Henderson has devoted hundreds of hours trying to get to the truth. They now have an unreserved apology and as much acceptance as the NHS ever offers: poor care ‘may have contributed’ to Robert’s death.
Proving cause and effect in medicine is notoriously difficult, which is why most medical litigation cases flounder. But Marjorie Henderson, now 83, only ever wanted the hospital to be honest about its mistakes and to show that they’d learned from them to prevent poor care happening to others. She has met two other women locally who are unhappy about how their husbands died in Treliske, but such is the culture of cover up in the NHS most people give up seeking the truth. The new chief RCHT executive, Lezli Boswell, is to be commended for her honest and transparent approach. But the lesson again for the NHS is that the harm of poor care is greatly increased by covering up, and it can scar for life. As Marjorie puts it; ‘I met Robert when I was 22, and he was my life. There has not been a day in the last 14 years when I haven’t missed him terribly.’