A coroner has determined that a series of severe and unacceptable blunders preceded the death of an elderly Brighton man at a hospital in the city.

Arthur Brooke Craig, aged 77, passed away on June 26, 2024, several days after a senior colorectal specialist performed surgery to remove a growth from his abdomen at the Royal Sussex County Hospital.

Proceedings at Horsham Coroner’s Court revealed that during the procedure, the surgeon opted to excise the patient’s colon instead of proceeding with a minimally invasive technique.

The medical professional neither consulted a colleague nor informed the individual beforehand that such a change might prove necessary.

Additionally, the specialist failed to thoroughly review the patient’s complete medical history prior to operating.

The initial medical certificate listed sepsis arising from a perforated bowel as the cause of death.

During the second day of the inquiry, it emerged that Mr Craig, a Brighton resident, underwent surgery despite having a significant cardiac condition.

Furthermore, he received no intravenous hydration for a full day following the procedure.

Coroner Gareth Jones stated that the situation represented an exceptionally serious degree of negligence.

The failure to identify the patient’s heart complaint was characterized as deeply troubling.

The court was informed that medical personnel overlooked the cardiac condition because they neglected to scroll through his electronic documentation, meaning the relevant information vanished from view.

Following the operation, Mr Craig was transferred to a standard ward where his fluid balance received no monitoring, despite the emergency nature of the bowel surgery.

The court heard that this failure to provide adequate hydration played a role in his death.

No post mortem examination was conducted after his passing.

The coroner determined that not all treatment alternatives were presented to Mr Craig before surgery, including a less invasive surgical approach.

The coroner observed that Mr Craig and his relatives were not offered the possibility of a de-functioning stoma.

Had this option been presented, the patient would likely have chosen it and his survival prospects would have improved considerably, the coroner stated.

When asked whether the absence of fluid replacement contributed to Mr Craig’s death, expert witness and consultant colorectal surgeon Professor Steven Brown confirmed this assessment.

Professor Brown indicated that the hospital failed to properly evaluate the risks posed to Mr Craig by undergoing major surgery.

The failure to administer fluids post-operatively meant that his rapid decline was initially attributed to dehydration, delaying recognition of the actual fatal complication.

He noted that the nature of his complication would likely have been identified sooner.

Had earlier recognition occurred, the patient would have been in better condition to potentially undergo further surgical intervention.

The professor described the hospital’s risk assessment as inadequate, pointing out that it failed to account for additional risk factors including the patient’s heart condition and previous cerebrovascular event.

The coroner noted that Mr Craig was a well-regarded individual who had received cardiac treatment in France in 2013 and at the Royal Sussex in 2016.

He was readmitted to the same Brighton hospital in 2017 after suffering a stroke.

His daughter, Professor Cathy Craig, persuaded him to return to hospital in May 2024, where initial treatment addressed a significant stomach ulcer.

Imaging studies subsequently identified a large, locally advanced growth.

The coroner indicated his disagreement that all alternatives had been properly communicated to Mr Craig.

Dr Marc Lamah, the colorectal specialist who performed the operation, had been prohibited from independent practice due to safety concerns while working at the Royal Sussex County Hospital.

The coroner noted that Dr Lamah claimed to have outlined all available options.

However, no supporting documentation exists and family members do not recall such a discussion occurring.

The coroner stated he found Dr Lamah’s account unconvincing.

Had the surgeon been aware of all alternatives, he would probably have chosen the least invasive approach, improving the patient’s odds considerably.

The coroner further noted that the surgeon could and should have obtained a second opinion.

Dr Lamah stated he was unaware of the extent of Mr Craig’s cardiac issues and maintained that the anaesthetist should have flagged this information.

The coroner rejected this explanation, indicating that given Mr Craig’s advanced age, cardiac condition, previous stroke and reluctance toward surgery, the procedure might not have been undertaken at all.

Dr Steven Drage, Dr Lamah’s line manager, acknowledged the Trust’s failures regarding the patient’s transfer to a general ward and the 24-hour period without fluid administration.

The coroner concluded that Mr Craig ultimately died from a perforation occurring after surgery.

Without a post mortem examination, it remained unclear whether the bowel or the ulcer had been perforated, with either potentially resulting directly or indirectly from the surgical intervention.

The court heard that Mr Craig’s cardiac condition remained uninvestigated before surgery, despite his daughters raising this matter with medical staff.

The cardiac complaint had been documented during his treatment at the same facility merely a week earlier.

His cardiac failure and prior stroke, both managed at the Royal Sussex, were not factored into the risk assessment for major surgery.

Dr Drage explained that his understanding was that the information disappeared from the bottom of the page.

Staff should have scrolled down, but the details were not immediately accessible at the time.

The coroner indicated that such fundamental information should have been readily available.

Professor Craig informed the court that surgical stress may have caused the ulcer to perforate.

She described speaking with her father as his condition worsened following the operation.

She stated that he wanted to understand what had occurred and expressed a desire to simply die.

She believed something had gone wrong with the surgery.

He passed away several days subsequently.

Professor Craig explained that her father wished to return to Northern Ireland, where he had worked as a sheep farmer.

He wanted a significant funeral and to be interred in Armoy alongside his parents.

He wished to go home.

She received a message requesting she purchase a burial plot in Ireland.

He told her he did not want surgery, he wanted to return home.

The situation was distressing, with frantic attempts to obtain information.

He asked whether the surgery had been a mistake.

She felt terrible, believing she had influenced his decision during the conversation with the stoma nurse.

His condition deteriorated gradually, and he was aware something was amiss.

Approximately a week after the discussion with the stoma specialist, Mr Craig signed a consent form for the operation without his daughter being present.

Professor Craig told the court she had no knowledge of which procedure he had agreed to and was absent when he signed the form, despite holding power of attorney and hospital documentation indicating she was to be given opportunity to discuss this matter with him.

During the operation, Dr Lamah decided to abandon the planned laparoscopy in favour of excising the growth and Mr Craig’s colon.

Dr Lamah stated he had been practising as a surgeon for 25 years and had performed procedures on more than 1,000 patients.

He told the court he could not obtain a second opinion before operating because the weekly surgical meeting had already concluded and he could not contact colleagues on a Friday evening.

Dr Lamah acknowledged that he had not reviewed all of Mr Craig’s documentation before operating and described proceeding with colon removal without warning his patient this might occur as merely a technical matter.

Two separate malignant growths were discovered during the procedure.

Emma Corkill, acting for the family, questioned the surgeon regarding his failure to mention explaining surgical risks to Mr Craig in any statements prior to the hearing.

Dr Lamah stated that he could not recall the precise details.

He would have provided a general explanation.

Either a major operation or simply creating a stoma with reduced risks.

He did not remember.

Ms Corkill pointed out that neither option appeared in his statement.

A year later, in his supplementary statement, he had not mentioned offering two surgical alternatives.

Today was the first occasion he had raised this matter.

The surgeon confirmed this was correct.

Dr Lamah stated that the operative risk was considerably lower than the risk of declining surgery.

The danger was between more than five percent or certainty of dying from the cancer.

Professor Craig described struggling to obtain any information following the operation.

She encountered Dr Lamah, shook his hand and inquired about the outcome.

He responded that he had no time to speak with her.

He walked past her and this left her very unsettled.

She approached him again and he took her aside.

He told her he had considered closing the wound but the procedure proved more extensive than anticipated.

He was concerned about sepsis and similar issues.

Dr Lamah stated he acted in the patient’s best interests and with full consent, despite the family not being informed of the risks prior to the laparoscopy.

After examining the growth, Dr Lamah stated he chose to remove it.

His view was that he could remove it safely and provide a reasonable chance of survival and potential cure.

Had he not done so, the patient would have died.

Ms Corkill acknowledged that this was his decision to make.

Dr Lamah responded that it was not.

The consultant told the court that the choice was between removing the growth or dying from it.

Whether the patient fully understood, the surgeon believed he possessed full mental capacity.

In his assessment, he had the ability to comprehend and decide.

The surgeon proceeded with removing the growth and Mr Craig’s colon.

Dr Lamah stated that waking the patient to ask would have served no purpose.

His assessment was that he could not cure the patient.

Surgery involves an intent, either curative or palliative.

He considered cure unlikely while still hoping a curative outcome might be possible.

The situation was not straightforward.

The surgeon does what is possible in the patient’s best interests.

The patient agreed to surgery and comprehended the alternatives, either dying from the growth or from the operation.

This was his firm view and conclusion.

It had become necessary to proceed as he did.

In his assessment, the patient had given consent to remove the growth if feasible.

Waking him to ask would have served no purpose.

Dr Lamah informed the court he now believes his operation had no connection to Mr Craig’s death.

The consultant suggested his death was more likely attributable to an unrelated perforated ulcer.

No post mortem examination was performed.

Dr Lamah was suspended in 2023 when Nuffield Health grew concerned about his complication rates.

Data indicated that one third of his patients experienced a moderate harm event over a twelve-month span.

The acceptable rate should be below five percent.

Mr Craig’s daughter delivered an emotional tribute to her father at the commencement of the two-day inquest.

She described her father as an independent spirit who taught his family to respect everyone.

The grandfather of twelve had six daughters who held him in great affection.

She stated that he was unconventional and disliked conformity.

He possessed a wonderful sense of humour and enjoyed sharing stories.

Big Craig loved telling tales and reading Sunday newspapers.

He taught them to always see the best in people and treat everyone with respect regardless of their status.

During the period of civil unrest, he established the Armoy Rugby Club as a means of bringing his community together.

She expressed gratitude for the numerous life lessons he provided.

They all miss him terribly.

The coroner recorded a narrative conclusion and directed the Trust to submit a statement within 28 days detailing improvements to their patient consent policies.

Addressing Mr Craig’s family, the coroner stated his hope that answers had been provided.

He expressed his sorrow that their attendance had been necessary.