Inquest: Gran suffered raft of complications following surgery at UHCWIvy Madziva
Margaret Jones underwent multiple procedures but died on March 9.
University Hospital in Coventry
A gran-of-eight who went into hospital for a routine heart operation died five weeks later having suffered injuries during further procedures.
Margaret Jones, 74, died at University Hospital in Coventry earlier this year leaving behind her husband of over 50 years.
At an inquest into her death today her family said there was “no direct leadership” and the doctors caring for her were “all singing from different hymn sheets”.
Mrs Jones eventually died of sepsis after developing problems with her bowel following the heart surgery.
But the court heard she had also suffered an injury to her trachea when a procedure to help her breathe went badly wrong.
In evidence it was heard the grandmother-of-eight suffered a 4cm tear which was caused when a wire “kinked” during a tracheotomy.
Mrs Jones underwent “multiple procedures” while at the hospital in Walsgrave, but died on March 9, 2018.
A coroner today concluded that she died of sepsis arising from peritonitis – as per the post-mortem examination – but added that incidents at the hospital, although not a direct factor, “in combination did contribute to her death”.
Dr Roger Townsend, a consultant at UHCW and who led the Trust’s investigation into Mrs Jones’ death told the family: “I apologise on behalf of the trust.
“We are very sorry and are doing what we can to stop this happening again.”
Concerns with UHCW treatment
Mrs Jones’ daughter, Deborah Mather, gave evidence at the inquest at Coventry Council House and described her mother as “spirited and young at heart”.
Mrs Mather said: “She was very loving and thought the world of her eight grandchildren, and was a massive part of our lives.”
When asked what her main concerns were regarding the care her mother received, she said: “My main concern is her trachea injury. It’s a very, very rare occurrence.”
Other issues raised by Mrs Jones’ daughter include “no direct leadership” among the doctors caring for her mother, with her stating: “The two main people were on annual leave, which isn’t a problem, but there was no handover to someone of the same calibre and no care plan.”
She described the doctors as “all singing from different hymn sheets”.
The inquest was heard at Coventry City Council chamber
‘ The Iron Lady’
The inquest heard Mrs Mather say that she told doctors at UHCW that her mother had a “distended and firm” stomach “about a week before” she was taken for a CT scan.
She said the family were told that doctors “weren’t worried” about her stomach and their “main concern was her airway”.
Mrs Jones’s daughter also stated that “nursing staff couldn’t believe how strong she was and how many procedures she had come through and survived”.
She said her mother was referred to as “the Iron Lady” and believed that “if she had been given that extra week” – after being told about her distended stomach – “then the outcome would have been different”.
Thomas Barker, the cardiac surgeon who carried out Mrs Jones’ heart surgery, told the inquest that the surgery was “uneventful”.
But three days later the ischaemic bowel was found and Dr Barker said: “Complications like this do happen. In this scenario there was found to be scar tissue inside her abdomen.”
He said a “pre-existing” issue “could have been exacerbated by drugs during anaesthetic”.
On February 8, Mrs Jones underwent bowel surgery and a few days later she had to go back on the ventilator due to breathing problems.
Dr Barker said it was likely that the “two major surgeries she had had would have an impact on her lungs”.
A decision was then taken to carry out the tracheotomy on February 13 however a wire used in the procedure developed a ‘kink’.
He said: “There was no doubt it hadn’t gone well.
“There was an issue with kinking in the line. An injury could have been caused or a hole made in the trachea.”
Julie Midgeley, the barrister for UHCW, asked Dr Barker if he agreed with the family that there was “no direct leadership” during periods he was away on annual leave.
He said: “It’s horrible to hear the family feel there’s a lack of leadership. We are on the phone all the time and talking to colleagues.”
Dr Vadim Iakimov, who carried out the tracheotomy, said the first attempt failed and, instead of using a different, smaller tube, he believed the original line was still useable.
Asked by the family’s lawyer if there was an opportunity to halt the procedure, the doctor agreed but said: “There was no sign of severe damage so I thought the main trouble was the size of the trachea”.
A 4cm tear was eventually discovered in Mrs Jones’ trachea, described in court as a “seriously big tear”.
However it was also said it was not clear exactly how that injury had been caused.
CT scans carried out after February 28 showed a build up in fluid in Mrs 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 replies 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 post-mortem 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 post-surgery.”
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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