Failures in hospital care of postman

A“NUMBER of shortcomings” have been identified in the care given to a man who died in hospital.

Robert Huw Summerhill died in the early hours of Christmas morning in 2019 after being admitted to the Royal Glamorgan Hospital with back pain and vomiting on December 23. Mr Summerhill, from Porth, was 42 years old at the time of his death and was working for Royal Mail as a postman.

An inquest at Pontypridd Coroners’ Court yesterday heard Mr Summerhill was diagnosed with severe acute pancreatitis and a plan was put in place for his treatment including monitoring his fluid input and output – a vital aspect of treatment for pancreatitis.

Coroner David Regan described how there were at least three shortcomings identified with Mr Summerhill’s care during his short period in hospital.

Evidence from doctors told how Mr Summerhill – the brother of Cardiff Blues winger Aled Summerhill – was on and off the acute care ward for several scans during the day on Christmas Eve, which meant his fluid output was not recorded by nursing staff.

At the hearing Debra Matthews, head of nursing for the acute services at the Royal Glamorgan Hospital, described how an investigation by the health board has since discovered that because of his preference not to be catheterised, Mr Summerhill should have been escorted off the ward to attend multiple scans in order to record any passing of urine. However, this did not happen and Mr Summerhill left the ward to attend a CT scan, an MRI scan and an ultrasound scan on his own. The hearing heard how Mr Summerhill passed urine three times within that period but the output was only recorded once.

Describing the importance of monitoring fluid input and output, Dr Nader Naguib, on-call consultant at the time, said: “The function of the pancreas is mainly digestion. The treatment is always to give as much fluid as is lost. The way we can know how much they need is to monitor how much fluid they lose.”

Mr Summerhill was admitted to the hospital’s A&E department at 11.30pm on December 23 after suffering with worsening back pain for the preceding two days.

Blood tests found inflammation of the pancreas and a diagnosis of acute severe pancreatitis was given.

Dr Naguib said Mr Summerhill’s condition was measured on a chart of one to 10 and recorded a score of two on the morning of Christmas Eve, which is the lower end of the risk scale. However, at 4.20pm nursing staff measured a score of five.

Mr Regan said: “That score should have resulted in a doctor to be called and that doctor should have been a surgical team. That did not occur and members of the surgical team were unaware.”

Mr Regan said that this was the second of the three shortcomings identified, the first being the inability to monitor Mr Summerhill’s urine.

The third shortcoming Mr Regan identified was the lack of an escalation plan in the instance that Mr Summerhill was to be transferred to intensive care. Dr Naguib said a registrar on shift had discussed this with a member of the ICU team who were aware of Mr Summerhill’s situation but no formal plan was drawn up.

Mr Summerhill was transferred to the surgical ward from the acute ward at 9.15pm on Christmas Eve. By 11.30pm it was clear Mr Summerhill was too ill to survive and he died at 4.20am on December 25.

A pathology report discovered Mr Summerhill had hemorrhagic severe acute pancreatitis as well as liver cirrhosis, likely caused by longer-term alcohol consumption.

Mr Regan recorded a conclusion of natural causes.