Gran suf­fered com­pli­ca­tions after rou­tine heart op, in­quest told

Coventry Telegraph - - NEWS -

Jones’ ab­domen, point­ing to a di­ag­no­sis of sep­sis.

A scan on Fe­bru­ary 20 how­ever, had showed no fluid.

Dr Roger Townsend, an in­ten­sive care con­sul­tant at UHCW, was asked to lead the hos­pi­tal’s in­ves­ti­ga­tion in to the care of Mrs Jones.

He told the in­quest that a tear be­ing caused dur­ing a tra­cheotomy is “very, very rare”.

Un­der ques­tion­ing from Mr Moat, Dr Townsend said that some of the ac­tions that the hos­pi­tal would usu­ally take - such as some CT scans - did not take place for Mrs Jones as they were wor­ried that do­ing so could pos­si­bly lead to los­ing her air­way.

These were in the af­ter­math of the failed tra­cheotomy on Fe­bru­ary 13.

Miss Midge­ley asked Dr Townsend if he “un­der­stands the ra­tio­nale” that Dr Iaki­mov used when car­ry­ing out the tra­cheotomy on Mrs Jones.

Dr Townsend said it is “ex­pli­ca­ble” but it did “ex­pose Mrs Jones to an un­nec­es­sary risk”.

Dr Townsend stated that he wished the “way the wire had been used” in Mrs Jones’ tra­cheotomy had been “chal­lenged”.

Speak­ing di­rectly to Mrs Jones’ fam­ily, he says: “I apol­o­gise on be­half of the trust.

“We are very sorry and are do­ing what we can to stop this hap­pen­ing again.”

Iver Jones replied by say­ing: “I think about her (Mrs Jones) ev­ery night. My last mem­ory of my wife was her in a hos­pi­tal bed, after 60 years.

“I had to vi­su­alise the beau­ti­ful lady she was.”

Mr Pegg gave a nar­ra­tive con­clu­sion in which he agreed the cause of death given in the post­mortem ex­am­i­na­tion as sep­sis.

He said that some of the pro­ce­dures that hap­pened at the hos­pi­tal, although not a di­rect fac­tor in her death, “in com­bi­na­tion did con­trib­ute to her death”.

Speak­ing about the use of the same wire in the two tra­cheotomy at­tempts on Fe­bru­ary 13, he said that the “whole pro­ce­dure was out of con­trol”.

Mr Pegg stated: “Mar­garet Jones un­der­went elec­tive surgery on Fe­bru­ary 5, 2018, and three days post-surgery she de­vel­oped an is­chaemic bowel and un­der­went small bowel re­sec­tion.

“Fol­low­ing surgery she de­vel­oped res­pi­ra­tory fail­ure and had a tra­cheotomy eight days post­surgery.”

He said this re­sulted in a tra­cheal tear and a col­lapsed lung, and she un­der­went “mul­ti­ple pro­ce­dures” be­fore dy­ing on March 9, 2018.

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