Source · Prevention of Future Deaths

Barbara Harrison

Ref: 2015-0277 Date: 13 Jul 2015 Coroner: John Pollard Area: Manchester (South) Responses identified: 0 / 1 View PDF

Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.

Date 13 Jul 2015
56-day deadline 8 Sep 2015
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Inappropriate physiotherapy contributed to surgical complications, and critical equipment failed during emergency surgery due to flat batteries, leading to a 'panic situation'. Family members were also distressed by public disclosure of a cardiac arrest.
View full coroner's concerns
After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter: This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy, as the surgeon and the anaesthetist both indicated that did not do so and would not have done so. During surgery to repair the oesophageal pouch; there were a total of three attempts to site an endo-tracheal tube and on each occasion it failed_ Part of the reason for this was that it was found that the batteries for the fibre optic tube were flat and inoperable. No replacement could be found. averred that never a light source at all" during the operation: This is an unacceptable situation during_a critical operative they "we got procedure: He then went on to say The need for an endoscope was critical and this is now a panic situation with the possibility of something going catastrophically wrong" Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital: As they were waiting; heard one of the porters shout out "we have got a cardiac arrest in theatre. This caused them extreme distress and alarm_
5. After the first surgery had taken place; the family noticed there was a and very obvious swelling around the neck and face of Mrs Harrison: did the nurses not note this and act upon it earlier?

Report sections

Investigation and inquest
On 13'h February 2015 commenced an investigation into the death of Barbara Joan Harrison dob 28"h August 1944. The investigation concluded on the 13"h July 2015 and the conclusion was one of Misadventure_ The medical cause of death was Ia Mediastinitis
Circumstances of the death
In late January 2015 Mrs Harrison had a scan of her neck as she had been experiencing worsening symptoms of difficulty swallowing and regurgitation. Surgery by way of stapling had earlier been attempted at the Regency hospitalin Macclesfield, but this proved unsuccessful and she was referred to at the Alexandra Hospital, where she was admitted on the 5"F-ebruary and operated upon that day Post operatively she developed significant surgical emphysema and an undetected mediastinitis.
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action:

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Report details

Reference
2015-0277
Date of report
13 July 2015
Coroner
John Pollard
Coroner area
Manchester (South)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 8 Sep 2015.

Sent to

BMI Healthcare Limited

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