The solicitor representing the family of a woman who died following an operation because the hospital had no emergency blood supplies available says the error was an ‘enormous breach of care’ in which a ‘life-saving operation resulted in a completely avoidable death’.
Irmgard Cooper, 85, had come through a serious but successful operation to repair a large bulge in the main artery to her heart.
However, when doctors at Northwick Park Hospital, London, started to release clamps and re-circulate blood around her body, her blood volume dropped dramatically, requiring replacement.
Although cross-matched blood had been pre-prepared for her operation, an inquest heard it was not on standby at the time and had actually been sent back to the blood bank, as Mrs Cooper’s name had been spelt incorrectly on the supplies.
When the surgeon carrying out the procedure questioned the anaesthetist as to why he wasn’t giving extra blood supplies when needed, he was told for the first time that none were available.
The surgeon re-clamped the artery in an attempt to save the situation, but it was too late and Mrs Cooper began to suffer massive internal bleeding and began haemorrhaging all over her body.
It took approximately two hours for the replacement cross match blood to arrive – a time Mrs Cooper would have been able to survive had the anaesthetist – who was aware there was insufficient blood on standby – told the surgeon and delayed the process of releasing blood around the body, the inquest heard.
Instead, all the blood in Mrs Cooper’s body was lost, and had to be replaced in entirety due to her critical condition.
She effectively died on the operating table and was pronounced dead later that night.
Medical Negligence Specialists
Hudgell Solicitors’ specialist medical negligence solicitor Renu Daly, who attended the inquest with the family, says lessons must be learned to prevent such ‘devastating errors’ being made again.
She said: “The first error was the mis-spelling of the patient’s name on the blood sample. The lack of communication between the anaesthetist and the surgeon over the absence of blood was the second error.
“If the surgeon had been aware, he could have delayed the unclamping for a further two hours, which would have ensured Mrs Cooper remained stable until the correct blood arrived.
“At the unclamping of the second leg, the die was cast. The catalogue of errors left the surgeon in an impossible position, as once he had unclamped the second leg, not knowing blood was not on standby, the clock couldn’t be turned back and the situation was irretrievable.
“When the cross-matched blood with the wrong name on was returned, the anaesthetist should have ordered O Negative blood immediately, as that can be given to people of any blood type, but he didn’t.
“Mrs Cooper was effectively dead from the time she arrived in intensive care, she was already suffering from catastrophic internal bleeding which meant death was inevitable.
“This catalogue of errors demonstrates an enormous breach of care and has had a devastating effect on her frail elderly husband, children, and grandchildren. It was meant to be a life-saving operation, but it resulted in a completely avoidable death.
“The family is now receiving our support and advice as they want to be certain that this matter is publicly investigated and exposed, and that devastating errors such as these are never able to happen again.”
London North West Healthcare NHS Trust has admitted full liability for Mrs Cooper’s death.
Her daughter, Lorraine Booker, who had waited at the hospital during the procedure, said the surgeon spoke to her afterwards and initially reassured her that everything had gone as planned, apart from a “little problem” with her blood clotting.
She said: “I phoned home and told my father and the rest of the family that she had come through the operation, which devastates me now.
“I went to intensive care to see her, I took one look at all her readings and felt her body, which was ice cold, and I knew she was going to die. She was lying in a pool of blood which was running off the bed. The floor was drenched in blood.
“My father has suffered from nightmares over my mother’s death ever since. We just feel very let down and betrayed by the hospital for a death that should never have occurred.”
The day after her mother’s death, Mrs Booker was contacted by the Coroner’s Office to be informed there would be a post mortem and an inquest into her death, which the family welcomed.
It was then that they discovered a mis-spelling of her German-born mother’s name from ‘Irmgard’ to ‘Irngard’ had been the trigger which ultimately led to her death.
A Serious Incident Investigation Report subsequently conducted by a panel at Northwick Park Hospital found that she died from serious blood clotting difficulties, cardio vascular collapse, haemorrhage, and that the delay in giving blood caused her death.
Mrs Cooper, who was married to husband Raymond for 62 years, and had two children and three grandchildren, had been admitted to the hospital on May 7 last year, for a repair of an aortic aneurysm.
The operation began at 11.49am, and involved the surgeon putting a graft on the aorta, which was clamped to prevent blood flow around the body.
Following the surgical repair, which went well, a number of clamps are then removed around the body one by one, allowing the blood to circulate again.
The cross-matched blood, with the wrong spelling on it, was sent back to the blood bank at 1.10pm.
At 1:30pm, the surgeon warned the anaesthetist that he was going to start the unclamping procedure, which he duly started at 1:45pm on Mrs Cooper’s right leg.
Another 15 minute warning was given to the anaesthetist ahead of unclamping the right leg, which happened at 2:05pm. It was at this stage, after the unclamping, that the surgeon noticed Mrs Cooper had a very weak pulse, and that extra blood was required.
It was only at this time that the anaesthetist alerted the surgeon to the lack of cross-match blood, with an emergency call made for O Negative blood as the artery was re-clamped.
Blood arrived but was not administered to Mrs Cooper until 3pm, by which time it was too late to save her.
The surgeon said he had not been made aware there was no blood available by the anaesthetist until the point when Mrs Cooper started becoming critically ill.
Mrs Cooper continued to seriously haemorrhage everywhere, and was given blood expanders and drugs to speed up her heart in an effort to keep her circulation going.
The medical team carried on administering blood for two further hours and made the decision to pack her abdomen and halt the operation at 5pm, when she was sent to intensive care to be warmed and stabilised, with a plan to operate again the following day.
However, she died at 11.54pm, 12 hours after the operation had been started.
Her daughter said: “I feel so let down after knowing what had happened with the blood delay. I feel betrayed by the anaesthetist and I want him struck off by the General Medical Council. The duty of care to my mother was breached.”
Coroner Andrew Walker concluded that Mrs Cooper died from neglect at an inquest at North London Coroner’s Court in High Barnet.
The coroner found gross failings in the failure to provide blood at a critical time when it was already previously known that blood would be required.
The inquest also found that the death was avoidable and the coroner’s conclusion was that the death was contributed to as a result of neglect.
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