THE death of a Worksop woman caused by ‘the failure of the system’ at Bassetlaw Hospital could have been avoided, an inquest heard.
The current system in place was described as ‘not safe’.
Ann Hugill, 69, of Plantation Hill, died in the hospital on 28th August 2010 from multiple organ failure after bleeding following surgery to treat breast cancer.
A spokesman from Doncaster and Bassetlaw Hospitals Trust said: “We can only apologise to the Hugill family - things did not go according to plan.”
An inquest at Nottingham Council House on Wednesday 27th June heard that Mrs Hugill ‘could still be here today’ if it weren’t for series of ‘weak links’ during her treatment.
“It was as if all of those involved were working with one hand tied behind their backs,” said Heidi Connor, HM Deputy Coroner for Notts. “No one was fully aware of what was happening.”
Significant failures in communication were highlighted in both the pre and post-operation treatment.
Mrs Hugill was diagnosed with breast cancer in 2010 when it was discovered that she also had non-alcoholic sclerosis of the liver - which raised concerns about her blood being able to coagulate.
To help prevent the risk of bleeding, a haematologist recommended that three units of fresh frozen plasma be given to Mrs Hugill before her operation. However, the court heard that during a phone conversation it was likely that the word ‘pre-operatively’ was ‘poorly transcribed’ as ‘perio-operatively’ - meaning that she would instead receive FFP during or even after her surgery.
Due to a further communication failure, Mrs Hugill only received one unit of FFP.
“Every opportunity was given for this to be picked up,” said Mrs Connor. “Tragically in this case it was not.”
While the coroner said she was ‘not convinced that two more units of FFP would have led to Mrs Hugill’s survival’, Mrs Connor did say: “If the post-operation deterioration and bleeding had been picked up by staff, on the balance of probabilities Ann would be alive today.”
“No one individual is responsible. This failing is the failure of the system as a whole.”
Mrs Connor recorded a narrative verdict, before calling for more adequate training and communication between staff, both pre and post operation at the hospital - particularly with agency nurses who she said ‘are often the weakest link’.
“The system at Bassetlaw Hospital is not currently safe,” she said. “I will be writing to the Chief Executive of the Trust.”