A grandfather died after doctors failed to manage well-known complications of a controversial form of surgery, a coroner has ruled.

Graham Coker, 59, of Windsor Avenue, Margate, underwent upper gastro-intestinal (GI) surgery at Maidstone Hospital in 2012 - a specialist procedure meant to be a minimally invasive way of dealing with stomach cancer.

He was diagnosed with the disease in his oesophagus 18 months before, after complaining of pain while swallowing, and was given a course of chemotherapy.

Once it was established the treatment was not working, discussions were held over the possibility of undergoing the specialist keyhole “salvage” surgery at the hospital.

However, an inquest at the Archbishop’s Palace in Maidstone heard that Mr Coker was not fully warned of the risks, as staff shortages meant consultations were carried out by an inexperienced, junior doctor who gave him information that was “incorrect, confusing and misleading”.

Mr Coker - a man who according to wife, Deborah, “wouldn’t even buy a vacuum cleaner without researching it for hours first” - agreed to the operation which took place on December 10, 2012.

Coroner Allison Summers said it was regrettable the patient had only met the surgeon, Ahmed Hamouda, on the day itself, where, she said, it would be inferred Mr Coker would have been told directly about the risks.

During the surgery, the tumour was successfully removed, however an issue arose with blood supply, meaning a conduit to bypass the affected part of the oesophagus turned blue.

“Even to my untrained eye, the colour is very noticeable,” Ms Summers told the court.

Mr Hamouda said in his evidence the conduit had “pinked up” and improved by the end of the procedure, and didn’t feel it was necessary to make reference in his notes afterwards, because he believed the problem had been resolved and did not think it would impact on post-operative care.

However, John Whiting, a consultant upper GI surgeon at the Queen Elizabeth Hospital in Birmingham, said he would be “incredibly nervous” if he saw the conduit turn blue and even if it had improved, he would have been minded of potential problems and ready to intervene with an endoscopy to explore further.

“Failure to document the issue is, in my view, a deeply troubling aspect of this case,” Ms Summers said.

She added that “serious issues” over the competence of Mr Hamouda would have been raised if he had either not noticed the issue, or deliberately left it out of his notes.

The coroner said she was prepared to accept his account as “honest, but not reasonable” and failure to document it did indeed affect Mr Coker’s care from then on.

"It has been an extremely difficult for the family given the hospital has continuously blocked the progress of the investigation..." - Alex Coker

He was alert the day after the operation, but then became increasingly unwell, after it had emerged there was a significant leak from the conduit - a recognised complication of this type of surgery.

Mr Hamouda did then say in his notes to consider a CT scan and an endoscopy if Mr Coker’s condition did not improve.

The court was told the surgeon thought a plan was in place for an endoscopy but it was never carried out before he died on December 19.

Ms Summers said responsibility for the patient rested on the shoulders of Mr Hamouda as the treating surgeon, but accepted he was dependent on issues being brought to his attention by those providing day-to-day care.

“Failure lies primarily, but not exclusively, with Mr Hamouda - if he was not available he should have ensured somebody else could carry it out,” she said.

Ms Summers concluded an endoscopy between December 12 and 15 would have saved Mr Coker’s life, and he may still have lived with intervention on any of the three days after that.

A lack of communication meant those looking after him were unaware of their roles and the specific risks of an inadequate blood supply, she added.

The cause of death was given as gastric conduit necrosis.

Alex Coker said on behalf of the family: “After several years we are relieved that the truth has finally come out about the serious systemic issues. It has been an extremely difficult for the family given the hospital has continuously blocked the progress of the investigation.

“We are, however, grateful for the thorough investigation made by the coroner, but this cannot replace the hurt knowing our dad would probably be alive now, enjoying life.”

A spokesperson for Maidstone and Tunbridge Wells NHS Trust said: “We are sincerely sorry Mr Coker did not receive the standard of care to be expected and that this did not consistently meet the high standards we set ourselves and expect our patients to receive.

“We will quickly and carefully review the inquest’s findings to ensure we have learned every possible lesson from Mr Coker’s care and that these are part of lasting changes.”

The coroner also apologised to his family for the gap of more than six years between Mr Coker’s death and the conclusion of his inquest.

There had been difficulties in finding an expert witness and the Royal College of Surgeons, which wrote a damning report into the procedure, declined an invitation to attend feeling, it could not talk about the death.