A coroner has called for answers from bosses at Blackpool Victoria Hospital amid fears its failure to properly investigate a serious incident is putting lives at risk.
The hospital’s probe into the care given to Pamela Briggs, who died on her 69th birthday following routine heart surgery, took almost seven months to complete and failed to include a statement from a key witness.
Blackpool coroner Alan Wilson has now written to interim chief executive Wendy Swift to ask what action is being taken to address his concerns.
The trust, which has until mid-January to respond officially, said it had already launched a review of its procedures before receiving Mr Wilson’s letter, and said it would outline any proposed changes to Mr Wilson in due course.
Mrs Briggs’ sister, Chris Walton today said: “This can’t all be for nothing. Pam’s death has to at least make them look at their actions and change their ways so that future deaths are avoided. My sister mattered.”
Mrs Briggs, a former auxiliary nurse who lived in Ribble Road, Leyland and was a stalwart of St Catherine’s Hospice in Chorley, where she worked as a shop manager and volunteer, had an operation to replace a heart valve at the hospital on January 28.
Six days later she had a heart attack, but no angiogram – a study of the heart and blood flow – was carried out, Mr Wilson said.
After her condition worsened, despite subsequent treatment, she was transferred to the cardiac intensive care unit before moving to St Catherine’s on February 13 – her 69th birthday – following a second heart attack.
She died less than half an hour later from multi-organ failure, and as a result of the heart attacks, an inquest heard. The valve replacement, which had been successfully operated on, was found to be a contributing factor.
An investigation into Mrs Briggs’ care was launched after the surgeon who operated on her returned from holiday and voiced his concern at her deterioration.
Though Mrs Walton said she believes more could have been done to help her sister following her first heart attack, Mr Wilson recorded a conclusion of death by natural causes.
But he decided to issue a regulation 28 report, which is aimed at preventing further deaths, after the inquest, held at Blackpool Town Hall, heard the trust’s final investigation report was only submitted in early September – and did not contain the testimony of a cardiology registrar who ‘had important evidence to provide to the investigation’ and was questioned at the hearing for over an hour.
Mr Wilson said: “Determining conclusions based upon such incomplete information raises the concern that recommendations being made about future practice within the trust are ill informed, and consequently flawed, and less capable of addressing problems than should be the case.
“Deaths could result if inappropriate practices are not addressed and the aims of a SUI are not achieved.”
National guidelines, detailed in an NHS report titled ‘Serious Incident Framework, say ‘those involved in the investigation process must not be involved in the direct care of those patients affected’.
Yet the inquest heard a surgeon who cared for Mrs Briggs played a key role in the investigation.
Mr Wilson said asking the surgeon to co-author the SUI report was ‘concerning’ and said it both ‘risks the perception of a lack of transparency and robustness’ and reduces the impact of any recommendations.
He added: “The manner in which the SUI review process is operated within the Blackpool Teaching Hospital NHS Trust minimises the chance of meaningful and effective lessons being learned and creates a risk of future deaths.”
In a statement, the trust said yesterday: “HM Coroner gave a verdict of death from natural causes.
“In his determination he commented that he had found the evidence given by trust staff to be extremely helpful and he was not in any way critical of the care given to the deceased.
“HM Coroner is duty bound to issue a Regulation 28 letter if he feels that an organisation can take measures to prevent further deaths.
“He has expressed some concerns regarding the quality of the Trust’s Serious Incident report in this particular case.
“Prior to having received the Regulation 28 letter the Trust’s Clinical Governance team had already begun a review of the Serious Incident process.
“Once concluded the details of this review and any proposals for changes to process will be laid out in the Trust’s letter of response to HM Coroner.”
More than 400 people attended a memorial service for Mrs Briggs, who was divorced with two children and three grandchildren, which was held at St Ambrose Church in Leyland in March.
Mrs Walton added: “She had such energy and 100 per cent to whatever she turned her hand to. St Catherine’s was her life. It felt like home. That’s why it was so important that she returned to the hospice.
“She died within half an hour of being there, but I truly believe she held on to be able to do that. It is what she would have wanted.”