Hospital inquest

The solicitor representing the family of a 71-year-old pensioner, who died at Good Hope Hospital, has expressed concerns that an inquest held this week and its subsequent verdict has not asked the hospital to review their future policies and procedures.

A thorough investigation into how Mrs Lily Martin came by her death took place before Birmingham Coroner, Aiden Cotter. He heard in the one-day inquest that Mrs Martin, formerly of Manston View, Tamworth, was admitted to Good Hope Hospital with a history of gallstones and associated jaundice. She underwent surgery on the afternoon of 25th October 2005 for the removal of her gall bladder (cholecystectomy).

During surgery it is believed that an area in the region of her gall bladder was inadvertently lacerated in two places but went undetected for 11 hours. The alarm was only raised at 05.50 the following morning when nurses found that Mrs Martin had suffered a cardiac arrest. She was resuscitated by a crash team and rushed back to theatre where the bleeding points were found by an emergency team of surgeons. Unfortunately, Mrs Martins condition continued to deteriorate and she died later that night in intensive care.

Hospital inquest solicitor

The family's solicitor, Victoria Blankstone, from the Birmingham office of national law firm Irwin Mitchell, said: "The family of Lily Martin have suffered a great deal as a result of their mother's tragic death at Good Hope Hospital last October. Having heard all the evidence, the family hope that the Trust will now accept their failings and that valuable lessons will be learned regarding the care of patients after surgery."

Mr Cotter returned a narrative verdict and identified 7 serious failings in Mrs Martins care. He criticised the doctors for failing to ensure that Lily Martin, following her major operation, received any post-operative check by a member of the medical staff from the time she left the operating theatre at 18.35hrs on 25 Oct 05 until she was found in a critical condition at 05.50 hrs on 26 Oct 05. Doctors were also criticised for not leaving precise instructions about the observations for the nurses to follow.

Coroner report

The Coroner also criticised the nursing staff for failing to recognise the change in the observations and for not recording their findings in the appropriate manner. The Coroner's final criticism was that the staff caring for Lily Martin failed to realise that she was bleeding and take the appropriate action to get her back to the operating theatre. The family feel that because of these failings their mother was denied the opportunity to be saved by earlier surgery.

Mrs Martin's daughter, Janet Chattaway, from Seckington, Tamworth, commented: My family continue to be absolutely devastated by my Mothers death. Although we feel that the inquest answered many of the questions surrounding her death we really feel that the hospital should have been asked to review their procedures and policies to make sure that this type of tragic incident ds not occur again, or that if something similar arises it is dealt with more effectively.