OAP’s cardiac injury was not detected

Blackpool Victoria Hospital / Lancashire Cardiac Centre / cardiac unit / view'Exterior from Ring road
Blackpool Victoria Hospital / Lancashire Cardiac Centre / cardiac unit / view'Exterior from Ring road
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An elderly heart patient died after a cardiac injury sustained during an operation was not picked up, a coroner has ruled.

An inquest into the death of Brenda Nicholson heard she had undergone a heart bypass operation at Blackpool Victoria Hospital on February 28 2012, which was was described as having between a five and 10 per cent operative risk.

Blackpool and Fylde coroner Alan Wilson

Blackpool and Fylde coroner Alan Wilson

After the operation, 80-year-old Mrs Nicholson’s condition deteriorated and she suffered cardiac arrest in the early hours of the following morning - dying on March 5.

Surgeons performing the operation say at that time they had concerns over a faulty cable used during an echocardiogram test (echo), which is used to visualise how the heart is working at that time.

Augustine Tang, consultant cardiothoracic surgeon at BVH, told the inquest: “The machine was working fine.

“The only piece of equipment that was not reliable, and it’s been an ongoing issue, was a cable that connects the coronary artery to the cardiac monitor - that’s often inconsistent.

“If I remember correctly we did do a reading but didn’t feel it was strictly reliable.

“That was the only issue that bothered us.”

Alan Wilson, senior coroner for Blackpool and Fylde, asked him: “Was that an ongoing problem in terms of your work at the time?”

Mr Tang replied: “Yes, not just in our theatre.

“It’s something the department was aware of.

“We were down to a very low number of cables, not only for theatres but the Intensive Care Unit.

“Essentially there were not enough cables to go round.”

During the operation an injury was sustained to Mrs Nicholson’s circumflex artery, which is found within the heart.

The injury was not picked up on an echo undertaken immediately following surgery and was only discovered later, by which time it was deemed the risk of further operation to rectify it was too high.

Expert witness Gus Pullan, a consultant cardiac surgeon based at Liverpool Heart and Chest Hospital, produced an independent report into the circumstances surrounding Mrs Nicholson’s death.

The court heard Mrs Nicholson’s consent form had been signed by a junior doctor, which Mr Pullan found to be an unusual practice.

However he concluded Mrs Nicholson, a retired secretary from Harrington Avenue, South Shore, had received a “good standard of care” during her time at the hospital.

Addressing the issue of the faulty cable, he told the inquiry: “In all cardiac units the cables never last as long as we wish they would and don’t give the reading you expect to see.”

Delivering a verdict of death by misadventure at Blackpool Town Hall on Thursday, Mr Wilson said: “The point in relation to the consent procedure has been properly raised by the independent expert in Mr Pullan.”

He advised Mr Sharples, the legal consel representing BVH, to report the matter to the hospital authorities.

A spokesperson for Blackpool Teaching Hospitals NHS Foundation Trust said: “The Trust wishes to pass on its sincere condolences to the family of Mrs Nicholson and is sorry for the distress they have been through.

“We hope that the conclusion of the inquest has brought some assurance to the family in that an independent expert confirmed that Mrs Nicholson received a ‘very good standard of consultant led care’ by the teams in the theatre and Intensive Care Unit.

“It was identified at the inquest however that Mrs Nicholson suffered from a rare, but acknowledged complication, of the procedure and the Trust would be happy to meet with the family to discuss any outstanding questions they may have.

“The coroner did highlight areas for the Trust to consider in terms of one specific area of consent and it will look into its current procedures and see where improvements can be made wherever possible.

“The inquest also touched upon the alleged unreliability and lack of cable equipment at the time of the operation. The type of monitoring which required the cable equipment was only one element of the way in which we monitor a patient’s stability. The Trust has invested in new and additional cable equipment for its theatres.”