Hospital failed in its care of Jewish patient who died after cardiac arrest

Coroner says London Clinic nurse who removed Neil Shestopal's catheter did not follow proper procedure, but finds no evidence of gross negligence


A top private hospital failed in its care for a Jewish man who died while recovering from cancer surgery, an inquest has found. 

But coroner Dr William Dolman stopped short of ruling that Neil Shestopal's death was a result of gross negligence on the part of The London Clinic. 

Mr Shestopal, a retired solicitor, died aged 72 on November 13 last year from the effects of a cardiac arrest, which his family argued was caused by an air embolism – a blood vessel blockage caused by bubbles of air or other gas in the circulatory system.

The family contended that the embolism was the result of the improper removal of a vascath - a type of catheter (CVC) - by nurse Jose Lopez several months earlier on April 19. 

Sitting at Westminster Coroner's Court on Friday Dr Dolman ruled that there was uncertainty over the cause of the cardiac arrest. 

He said: "There are a number of possible causes: acute coronary event, or aspiration into the airways or air embolism.

"The cause of the cardiac arrest remains shadowy, and a matter of some speculation. 

"There are three potential causes posited - each has some value. Regarding an air embolism, whether it was the true cause was not supported by hard evidence.

"There is no convincing objective evidence for any of them."

Dr Dolman recorded the cause of Mr Shestopal's death  as septicaemia associated with a chest infection, associated with hypoxic brain injury secondary to a cardiac arrest following the removal of a central catheter. 

But the coroner he said it was "a matter of fact", that the recommended guidelines for the removal of the vascath had not been followed by Mr Lopez. 

Patients are supposed to be lying horizontally with the head facing down when vascaths are removed. Mr Shestopal was sitting in an armchair when Mr Lopez took the catheter out. 

Mr Lopez told the inquest that he had not wanted to disturb Mr Shestopal, who was recovering from two operations, and he did not anticipate such "tragic complications". 

Mr Lopez also admitted he had no experience of removing vascaths, and limited training in removing CVCs, from his time at St George's Hospital in south London. 

Despite this, he said, nurses and consultants and The London Clinic were happy for him to carry out the procedure. 

Dawn Shestopal, Mr Shestopal's widow, said she was disappointed the coroner had not concluded that the hospital committed gross negligence. 

Speaking following the coroner's verdict, she said she felt "bitter" that Mr Lopez continues to work as a nurse, and she would be concerned for other patients had The London Clinic not put in place enhanced safety procedures regarding the removal of CVCs. 

Nuala Close, the matron of the London Clinic, said yesterday that every nurse in the hospital now has mandatory training and assessment in removing CVCs. They are also only removed in "specialised areas" of the hospital. 

She said that before Mr Shestopal’s cardiac arrest there had been no such arrangements, and that Mr Lopez had not received any mandatory training in CVC removal from The London Clinic.

Mrs Shestopal reached a settlement with the hospital a number of weeks ago. Representing the Shestopal family, Anthony Metzer QC said it was rare that a civil case is settled before an inquest has been heard. 

In a statement following the inquest, a spokesperson for The London Clinic said: “Our thoughts and deepest sympathy are with Mrs Shestopal. This was an isolated accident and we have apologised to Mrs Shestopal unreservedly for what happened; the care we provided fell below the standards we set ourselves.

"We conducted an investigation in April 2016 and shared the findings with Mrs Shestopal at the time. We understand that the coroner's inquest was a very difficult time for Mrs Shestopal and for employees at The London Clinic and we will carefully consider what the coroner has said.”

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