Gran suffered complications after routine heart op, inquest told
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.