As an inquest into the death of a man recovering from surgery in a private hospital continues, the lead consultant in the room at the time has admitted to not checking all of the equipment. 

Phillip Morris, 48, died in St Anthony’s Hospital in Sutton while recovering from weight loss surgery which he was told would be “less risky than a knee operation”.

His wife Dana Morris, 48, has slammed the hospital for a “catalogue of errors” following her husband’s death.

Yesterday (Tuesday, February 6), Senior Nurse Michelle Forest told the inquest that one important piece of equipment was not working, and another was not connected to the ventilator correctly.

After a gradual deterioration in Phillip’s condition, there reached a point where Phillip went into cardiac arrest and hospital staff were simultaneously performing CPR and trying to make an airway to help him breathe.

Today (Wednesday, February 7), the lead clinician in the room, Dr Shukla, consultant intensivist, was put under the microscope as he gave evidence on his role in the final hours of Phillip’s life.

Due to the time-pressure of the emergency situation, Dr Shukla has confirmed that there was not time to follow ideal procedure.

One of these key pieces of equipment not checked was an ETCO2 monitor, which shows medical staff how well a patient is breathing.

Barrister Julian Matthews, representing Phillip’s family, questioned Dr Shukla on this piece of equipment:

How do you check if this piece of equipment is working?

The way we check is to blow into the end and see if the CO2 trace comes up on the monitor.


So, it is a very simple check that can be made to see if the equipment is working?



If you are moving a patient from one bay to another, it is important is it not before you start making the transfer to ensure the equipment in the bay you are proposing to move them to is all working and functional?

Absolutely correct.


Because the transfer, even if it is a tiny, short distance, involves disconnecting in the first bay and reconnecting in the second bay?



So, you should not even start to transfer until you have checked equipment in the second bay is fine?

In an ideal situation, yes.


Do you accept as the consultant in charge that you have an overall responsibility for the planning and execution of those things that need to be done in the run up to intubation?

Yes, but it’s team work and every member of the time knows what needs to be done by them.

That time, there was another priority that was competing with us.

When the transfer was happening, Dr Gabrov (Dr Kostadin Gabrov, ICU resident medical officer) was there, he is a trained anaesthetist and so he was a competent person to transfer Mr Morris from the side room to the ICU.


Why had you not considered the question of whether there was adequate space in the side room if something went wrong?

At that time it was the nurse in charge who said we should transfer him to give him more space.

It came from her and I agreed.


Why hadn’t you thought of it? Why was it her?

Because there were other things going on in my mind at that time and at St Anthony’s the nurse in charge knows the set up and layout better than any consultant.


Mr Matthews also pointed out that when Phillip was intubated for his initial surgery, he had been given an Oxford Help Pillow to help his breathing.

When asked why he was not provided one for this intubation, Dr Shukla said: “If I had chance after bringing Mr Morris from the side room to new bay and he was stable then I would have got everything there.

“But, it crashed very quickly and I had to run and start the process immediately.”

Mr Matthews later asked Dr Shukla if he had blown into the machine to see if it was working, or if he asked any other member of staff to do it, to which he said he did not.

Dr McCrirrick, a consultant anaesthetist, gave evidence today (Wednesday, February 7) as an expert witness.

When asked by the Coroner whose responsibility it is to ensure the equipment is working properly in this situation, he said: “The simple answer is that the ultimate responsibility has to be that of Dr Shukla.

“He is the consultant he’s in charge and he is the clinician about to anesthetise and intubate the patient so clearly he has the ultimate responsibility.

“However, setting up all the equipment is a team effort and other members of the team should have some input too.”

Phillip was initially supposed to have this surgery in an NHS hospital, however, when the pandemic hit these procedures were put on hold.

His wife Dana has said that Dr Khan offered to complete the surgery at St Anthony’s Hospital, run by Spire Health, in Sutton for £12,000 so that it could be completed sooner.

Phillip believed the surgery to be “a small serious risk for a life changing reward”.

Phillip was a writer, university lecturer and a trained actor and his wife describes him as “funny, focused and determined” adding that he was “the most intelligent man that I had ever met”.

In a statement heard by the Coroners Court on February 5, Mrs Morris explained that Phil suffered from severe obstructive sleep apnoea, requiring him to sleep with CPAP (Continuous Positive Airway Pressure) every night.

He was also a type II diabetic and had allegedly been thinking about how to lose weight for a long time.

Dana said that he had decided to go through with this surgery for the health benefits being a lower weight would give him.

The inquest continues.