A SERIOUS error made by a St Mary's Hospital doctor means he must refer himself to the General Medical Council following the death of a patient.

Coroner Caroline Sumeray did not find gross neglect at the inquest of 35-year-old Steven Hasler, but she asked Dr Ramesh Babu Chandrabhan Singh to refer himself to the GMC over a "big mistake" he made.

Mr Hasler died at home on February 14, 2019, two months after open heart surgery for aortic valve replacement.

His inquest took more than three years to get to the Isle of Wight Coroner's Court — partly due to the Covid pandemic and partly due to the difficulty of getting an independent witness who was a cardiothoracic expert to come to the IW.

The inquest was heard over ten hours this week, in the presence of Mr Hasler's family, who had long fought for answers over his death.

The inquest found that Mr Hasler developed a severe wound infection after his operation, which was overlooked but might have been detected had he not been discharged from St Mary's A&E when he presented himself there.

No recommendation for follow-up treatment with specialists at Southampton General, where he had undergone the surgery, was made.

Mr Hasler, of Arundel Close, Ryde, had surgery on November 22, 2018, to correct a congenital heart problem.

He developed a post-surgical issue whereby the wound hadn’t healed and was oozing.

He initially sought medical advice from St Mary’s, on December 1, 2018, for what was diagnosed as musculo-skeletal pain.

He saw his GP on December 7, for his leaking chest wound, but the focus of his consultation was around his excessive use of Pregabalin for pain relief.

Later that evening, he returned to A&E complaining of post-operative bleeding and was put on intravenous fluids and antibiotics, but no blood cultures were taken for examination.

At 12.46am he was seen by Dr Chandrabhan Singh who discharged him 12 minutes later.

He gave him oral antibiotics, with the indication that the cardiothoracic surgical team at Southampton General would be contacted the next day. This did not happen.

A discharge summary was described in court as "woefully inadequate" — it didn't say what medication had been dispensed or what follow-up was expected.

Mr Hasler was left not appreciating how unwell he was. He missed two subsequent medical appointments by not turning up.

His body became riddled with sepsis and he died.

Mrs Sumeray said: "There had been incomplete handovers of his medical care at St Mary’s hospital and a failure to recognise the seriousness of his condition. This significantly contributed to his death.

"Had there been an effective and prompt notification of his condition to Southampton General or a comprehensive discharge summary alerting his GP to the need for onward referral, on the balance of probabilities, he would have received appropriate care and treatment which may have saved his life."

The cause of death was sepsis, with a contributory cause of an endocarditis periaortic leak following aortic valve replacement.

Dr Chandrabhan Singh apologised to Mr Hasler's family.

He said with the benefit of hindsight he should have called Southampton General that night, and admitted Mr Hasler instead of discharging him, but added: "At that point I was honestly not concerned. The patient was keen to go home. Clinically, I thought he was stable."

Mrs Sumeray said Mr Chandrabhan Singh had made his decisions during a 24-hour shift, and she criticised the practice.

She said: "If someone is working 24-hour shifts, balls are going to be dropped. The doctor has been let down by the way the hospital was operating."

She said she was considering raising the issue with the secretary of state for health, via a Prevention of Future Deaths Report, and she told St Mary's medical director Stephen Parker she thought the days of 24-hour shifts "were long gone".

Mrs Sumeray acknowledged progress the hospital had made in improving their discharge summaries, in the time since Mr Hasler's death.

Mrs Sumeray drew a narrative conclusion into Mr Hasler's death, as no short-form conclusion was appropriate.

She offered Mr Hasler's family her condolences and thanked them for their patience in awaiting the inquest.