A Post Mortem with Sir Keith Simpson
‘These patients with heart disease don’t do very well with surgery do they,’ said Professor Sir Keith Simpson. He was taking me through the dissection of the patient’s heart. It was a coroner’s case. He was the coroner. The deceased had been my patient.
I felt guilty that her death might have been the result of a mistake I made in not prescribing her usual medications on the morning she had surgery. I had beaten myself up about it for several days but in the end it wasn’t relevant. Her death wasn’t my fault.
The deceased was a sixty year-old woman. She had been admitted for a mastectomy for breast cancer. She had rheumatic heart disease with atrial fibrillation and was on warfarin, an anticoagulant, because of the high risk of blood clots and a stroke.
I had checked on her potential for bleeding with the surgical senior registrar. He was insulted that I would question him about it, the implication being that his surgical technique couldn’t cope with her blood being a little on the thin side from her anticoagulation. I didn’t ask about her other therapy. In those days nil by mouth meant just that and we usually withheld all tablets on the morning of surgery.
She became breathless 12 hours postoperatively. I was called to see her. She was puffed but in no distress. Her heart rate was up at around 120 and her blood pressure on the low side at 100/60. Her venous pressure was not elevated and her chest was clear meaning there were no signs, at least clinically, that she was in heart failure. There was no evidence that she had bled significantly and the drains in the wounds were near dry.
Her electrocardiogram showed fast atrial fibrillation but no new changes. Her chest radiograph demonstrated a big heart, which was unchanged, with no signs of fluid in the lungs or of congestion of her veins. That meant there was no radiological evidence of failure. I was at a loss for a diagnosis but she had not had her usual treatment of digoxin or frusemide so I charted them.
I was concerned that I might be missing something and worried all night. When I say ‘all night’, I mean that I ended up with a restless sleep and woke up a couple of times thinking about her. Most doctors will know what I mean.
I got up to see her very early the next day. She was much the same. I spoke to the surgical senior registrar who just said, ‘Get a cardiologist’. I bleeped the duty registrar.
I had a couple of jobs to do and wasn’t on the ward when the cardiology senior registrar arrived and examined her. He had just finished looking at the chest X-ray when I got back.
‘She has heart failure … you’re mismanaging the case,’ he told me. I tried to explain that I didn’t think the X-ray had shown any evidence of failure but I was just a first year junior and he was a very senior registrar. He wouldn’t listen, dismissed me and left the ward.
The patient was taken to the coronary care unit, put on an ionotropic agent and given diuretics. She didn’t respond and got worse. She remained hypotensive and her urine output deteriorated.
She then developed abdominal pain and swelling so it became clear that it wasn’t just her heart that was the problem. She was taken back to the operating theatre and had a bowel resection for ischaemia.
She had also bled into her chest wall. A big haematoma was drained. Blood loss had been the explanation for her fast heart rate and low blood pressure. The diuretics she was given for the incorrect diagnosis of heart failure would have made it even worse.
Unfortunately she continued to deteriorate and died. A death after surgery meant it became a coroner’s case. I was delegated to be the team’s sole representative at the post mortem. It was expected that one of the doctors attended.
I went back and took a look at the notes. The cardiology registrar had crossed out his initial diagnosis of heart failure. He had written, ‘I was shown the wrong X-ray,’ suggesting that it was someone else’s fault. The obvious culprit was me. I was furious.
As every medical student learns, you are expected to check that the X-rays you look at are for the patient you think they belong to and that the date is right. The cardiology registrar was trying to cover up for his mistake. It was even worse because he had ignored my protests about his diagnosis and his interpretation of the X-ray.
Even more worrying was I found out the coroner’s pathologist was Professor Sir Keith (Cedric) Simpson. I was mortified. I had just read his popular book, ‘Forty Years of Murder,’ in which he recounted his experience as a Home Office pathologist. Simpson had been knighted for his expertise. He was then near the end of his career but was still head of department at Guy’s Hospital and a coroner’s pathologist.
In 1965 Simpson had identified the first ‘battered baby’ death but the case I had been most impressed with was of John Haigh, the ‘acid-bath’ murderer. John George Haigh (1909 -1949) was a serial killer. He was convicted of the murder of six people, although he later claimed there were nine. He had dissolved their bodies in sulphuric acid, and forged papers to sell their possessions. Haigh thought he would get away with it because he believed there needed to be a body for a murder charge. Simpson’s investigation of sludge at Haigh’s workshop revealed three gallstones. It was the key evidence that led to a conviction and Simpson’s evidence sent him to the gallows.
What would he uncover in this investigation? What would he do to me?
The Professor was a real gentleman. He asked me to assist with the post mortem and I had gowned up. He found evidence of very severe mitral stenosis. After his comment I relaxed. I hoped that the mask hid my expression of relief.
I got off without any criticism. The cardiology senior registrar went on to better things and became a London teaching hospital consultant and co-authored a textbook.
My decision not to stay on in London was partly influenced by the experience. I left for Africa and a peripatetic career that has taken me around the globe.
– Paul Reeve
Paul Reeve is a general physician in Waikato Hospital. He was brought up in Hong Kong, went to medical school in London and worked in Africa and Vanuatu before moving to New Zealand.