DCSIMG

Op mum ‘could have been saved’

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A mum of four died after hospital staff missed ‘a window of opportunity’ to repair damage done during an earlier operation.

An inquest on Thursday heard that Emma Hughes, 41, of Dunstable Road, Luton, had suffered serious complications during an operation to remove a kidney at the Luton and Dunstable Hospital.

Staff failed to realise that damage to a main artery was cutting off the blood supply to vital organs until several hours after.

She had further surgery but suffered three cardiac arrests on the operating table and died the following day, October 24, 2012.

Beds Coroner Tom Osborne heard from consultant urologist Ashraf Alum that there had been complications during the original operation to remove a kidney and tumour.

Mrs Hughes was later moved to the high dependency unit to recuperate. Mr Alum told the inquest at Ampthill, that although he did not give specific instructions to nursing staff to contact him if her condition deteriorated, he believed that all staff were aware that is what he preferred.

But the inquest heard that despite Mrs Hughes’ condition getting worse and notes from doctors and senior nurses suggesting Mr Alum should be contacted, he did not receive a call until around 4am the day after the initial operation.

Mrs Hughes was then operated on again at 5.30am on October 23.

A senior review carried out at the hospital following the death has since introduced an escalation policy which is prescriptive for all medical and nursing staff at the high dependency unit.

Dr Douglas Whitelaw, one of the authors of the report, said the policy was designed to change the culture at the hospital and ensure staff were empowered to call a consultant without fear of being reprimanded.

Of Mrs Hughes’ death he said: “There would have been a window of opportunitywhen the outcome would have been different.”

Mrs Hughes died of an intestinal infarction.

In a narrative verdict Mr Osborne said: “there were no written instructions to the nursing or clinical staff that the consultant should be contacted in the event that there was a deterioration in her condition.

“This resulted in a lost opportunity to return her to theatre earlier and render further medical/surgical treatment.”

 

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