Patient died after 'nurse failed to follow proper procedure', inquest hears

Removal of catheter 'most likely' to have led to cardiac arrest which resulted in death of retired solicitor Neil Shestopal


A nurse has admitted failing to carry out a medical procedure in the safest possible way, which "most likely" led to the fatal cardiac arrest of a Jewish patient at a private hospital. 

Neil Shestopal, a retired solicitor, died aged 72 from the effects of a cardiac arrest, which his family claims was caused by an air embolism – a blood vessel blockage caused by bubbles of air or other gas in the circulatory system.

An inquest at Westminster Coroner's Court, which opened on Thursday, heard this was "most likely" caused by the improper removal of a vascath - a type of catheter (CVC) - by nurse Jose Lopez at the London Clinic on April 19 2016. 

Dr Sarah Polhill, an intensive care consultant at the hospital, and nurse Hazel Glynn confirmed the usual procedure is to have the patient lying horizontally with the head facing down, although the court heard this was not always possible. 

Mr Shestopal was sitting up in an armchair when his catheter was removed. 

Mr Lopez admitted this was because he did not want to disturb his patient, who was fitted with a number of tubes after recent emergency surgery, and had recently vomited. 

Mr Lopez also said 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. 

Mr Lopez, who has worked as a nurse for 12 years, said: "(Mr Shestopal) was a post-op patient. He had quite a lot of lines coming out of him. 

"He had also just had a traumatic episode of vomiting. He was sitting in a chair and he looked relaxed to me. I didn't want to move him around - I didn't want to disturb him. 

"But I did not expect such tragic complications."

Dr Polhill, who cared for Mr Shestopal after his cardiac arrest, said she could not ignore the fact that the heart attack occurred so quickly after the catheter was removed. 

She said: "The temporal relationship between the two could not be ignored. Another thing that led me to believe this was the case was that [Mr Shestopal's] chest sounded bubbly. 

"Usually it's done lying down with the head down, but this is not always possible. The other thing we ask is for the patient to take in a deep breath. 

"On the balance of probabilities this was the result of an air embolism."

Mr Shestopal died from septicaemia and hypoxic brain injury on November 13 - the latter caused by a shortage of oxygen to the brain resulting from the cardiac arrest. 

Mr Lopez asserted that he asked Mr Shestopal to hold his breath while his vascath was being removed, which was one of the key safeguards in the procedure.

However, Mr Shetopal's wife, Dawn, a retired circuit judge who was in the room at the time, denied this was the case.

Nuala Close, a matron at the London Clinic, told the inquest that Paul Holdom, the hospital’s chief executive, had met Mrs Shestopal several times and had acknowledged that there were a number of occasions when her husband’s catheter could have been removed before it was.

Ms Close added that catheters were usually removed in “specialised areas”, such as the intensive care unit – rather than on the wards, although Mr Shestopal was on a ward when his was taken out.

She said procedures had since been put in place so that cathaters were never removed on the wards, and a “bespoke service” has been introduced, whereby every nurse in the hospital has mandatory training and assessment in removing CVCs.

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 and the London Clinic agreed a settlement before the inquest opened.

Acting for the Shestopal family, Anthony Metzer QC told the inquest that while the failings were Mr Lopez’s, the context in which he worked should be taken into account.

He said: “[Ms Close] has accepted that, but for these failings, Mr Shestopal wouldn’t have suffered the heart attack, which substantially contributed to his passing some months later

“There were systematic failures – it appears to be fairly clear that if someone had done it properly it would not have happened. In my respectful submission, you need to consider the issue of neglect.”

Mr Shestopal was a well-known figure in the Jewish community. His family received hundreds of letters of condolence after his death, and 400 mourners attended his funeral. 

Born in Wales in 1944, he was honorary cantor of Ealing synagogue for 40 years, and the founder of website Opera World. 

He was referred to the London Clinic to be operated on for cancer of the sigmoid colon on April 5 2016. 

Following a complication after the operation requiring emergency surgery, the catheter was inserted in the event that he would require dialysis treatment.

Mrs Shestopal recalled that, moments after his catheter was removed by nurse Lopez, he began to move his arms vigorously against his chair and "his eyes rolled back in his head". 

Mrs Shestopal said her husband was "passionate about life" who, as a solicitor, was "not just respected but loved" by his clients. 

A fan of opera since childhood, Mr Shestopal was also a season ticket holder at Chelsea Football Club and a member of the Marylebone Cricket Club (MCC). 

The  inquest, presided over by coroner Dr William Dolman, was attended by a number of his friends, including legal journalist Joshua Rozenberg. 

A verdict is expected tomorrow.

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