Pre-op shake up after woman’s death

Kathleen Hepworth

A hospital has been forced to shake up its pre-operative procedures after a Rochdale woman died following treatment for a leg ulcer.

Kathleen Hepworth (78) had a vein bypass operation on 4 August last year, but the results of a crucial medical test to assess whether she was suitable for the surgery were not looked at before she was wheeled into theatre at the Royal Oldham Hospital.

The former confectioner had a massive heart attack after the operation and deteriorated rapidly over a period of weeks, before she died on 6 September.

Consultant pathologist Alan Padwell told the inquest that Mrs Hepworth had high blood pressure and damaged heart valves and was at severe risk of heart failure.

But he said that she would not have died when she did if she had she not had the operation.

The doctor in charge of Mrs Hepworth’s care, vascular surgeon Taohid Oshodi, said that Mrs Hepworth had undergone an echocardiogram (ECG) on the Saturday before she was due in theatre on the Monday.

But the results were not available before the operation and the surgery went ahead regardless.

Mrs Hepworth suffered severe blood loss during surgery and she had a heart attack soon afterwards.

Dr Oshodi said that the ECG was a fairly crude assessment of heart health, but he added: “If I had seen the results of the ECG before the operation, I would have opted for a different type of surgery which is less invasive and involves less blood loss.”

Dr Oshodi could not explain what had happened in Mrs Hepworth’s case, but he said that an internal investigation had taken place after her death and a number of changes were now in place.

He said that the private company which carried out the ECG was not connected to the hospital’s internal computer system, so the results were not accessible.

But now all pre-operative test results were posted on to the hospital’s intranet system, so they could be viewed straight away.

Abnormal results were were now immediately flagged up with clinicians and results not filed until a consultant has signed and stamped them to ensure they had been examined.

Coroner Simon Nelson praised Mr Oshodi for his frank approach, but said that he would be writing to the Pennine Acute Trust to make absolutely certain that the new standards were being applied across the board.

“I want to make sure that I don’t have to deal with another case like this one in the future,” he said.

Mr Nelson recorded a verdict of natural causes, which were precipitated by surgical intervention which proceeded without the results of an ECG.

Speaking after the inquest, Mrs Hepworth’s daughter, Joanne Hepworth, said: “We’re pleased with the results of the inquest.

“After the operation it was one setback after another. Mum suffered terribly before she died and it was an absolutely awful time.

“The fact that changes have been made makes us feel better because we don’t want anyone else to go through what we have been through.”