A 17-year-old hairdresser bled to death for 15 HOURS when nurses failed check her properly after a surgeon tore an artery during a routine operation, an inquest heard today.
Bungling medics made 43 shocking errors while caring for tragic Victoria Harrison who was left to bleed to death in a hospital bed.
The pretty trainee hairdresser was so scared she even texted a picture of her blood-soaked T-shirt to her boyfriend hours before she died.
She was admitted to hospital for routine key-hole surgery on August 15 last year after suffering abdominal pains the day before.
But during the 30-minute op to remove her appendix, she suffered internal bleeding when surgeons tore a hole in an artery while inserting a micro-camera into her stomach.
Medics managed to repair the hole but she lost up to 400ml (over half-a-pint) of blood and she was sent to a ward at Kettering General Hospital, Northants., but died the next day.
An inquest at the Best Western Hotel in Corby, Northants., yesterday heard nurses failed to read her medical notes which indicated she had suffered a large bleed during surgery.
Shockingly, she was not properly checked and nurses failed to take her blood pressure which would have indicated her blood loss.
Despite complaining of being in pain nurses gave her morphine until she suffered heart failure and died at 7am on August 16.
Her death also sparked a huge investigation by hospital into her care.
A report by Kettering General Hospital NHS Foundation Trust found staff made 43 errors while caring for Victoria.
The inquest heard her surgeon Shady Hosny said one of the abdominal wall arteries started bleeding during the operation.
Within 30 minutes the bleeding had stopped and Victoria had lost 200-400ml of blood but she was stable with her appendix removed.
It was unclear from medical notes how much blood she had lost exactly but Mr Hosny confirmed it was more than normal during such an operation.
In a statement read to the inquest he said: “During the procedure, I noted that there was minimal blood yet as it was a small amount, I was not concerned at this stage and continued to perform the appendicectomy.”
Mr Hosny was later exonerated of blame following a hospital investigation.
When the two hour operation was completed at 4pm Victoria was then transferred to a recovery ward.
Gillian Joy, the recovery nurse looking after Victoria told the inquest she had not been told the patient had bled during the surgery and did not read the operation notes.
She said: “I would expect the scrub nurse to tell me about any excessive bleed. I would have then informed the ward nurse.
“Initially Victoria told me she had a slight pain but she was more concerned about feeling nauseous.
“Later she stated she was pain free and was just anxious to see her boyfriend.”
Victoria was then discharged to a main ward at 5.20pm.
Julie Walsh, a staff nurse at the hospital, was then in charge of Victoria’s care.
She gave her painkillers at 6.15pm at which point she was being comforted by fiancé Ashley Warner.
Hours after he left he was alarmed when Victoria, who he called ‘Tor’, texted him a picture of her bleeding.
In a statement he said: “We spoke for about an hour, Tor said she felt fine.
“She was looking forward to coming home the next day and telling me how everyone had to look after her and she wanted a bit of pampering.
“I left at the end of visiting, she still seemed fine, very relaxed and she was texting friends on her mobile phone.
“That was the last time I saw her.
“We were texting each other most of the evening, I’ve no idea what time it was that I got the first message from Tor saying that she was in pain, but the doctor had been and given her some pain relief.
“A bit later I then got a message saying that she was bleeding from one of the holes from the operation and she sent me a picture.
“She was wearing grey jogging bottoms, I can’t remember what coloured top she was wearing, but I could clearly see a large amount of blood on her abdomen.
“There was blood on her T-shirt and I could see the blood coming from one of the holes and I could see where the blood had trickled down her front.
“The next text I got from Tor said ‘nurse is here she’s sorting it now’.”
When Mrs Walsh finished her shift care assistant Debbie Sumpter took over at 5.30am on August 16.
She said in a statement read at the inquest: “I started the rounds at 5.30am and as I was helping another patient I looked over to Victoria and could tell something wasn’t right.
“She looked pale and stiff. I went over and shook her and shouted her name but there was no response.”
An arrest team then tried to resuscitate Victoria for nearly 40 minutes and she was given two units of emergency blood but she was pronounced dead at 7am.
The inquest is expected to finish today (Tue).
CATALOGUE OF FATAL ERRORS
1. Wrong surgeon documented on theatre documentation.
2. Communication of blood loss among theatre team.
3. Unsupervised student scrub practitioner.
4. Scrub practitioner not concentrating on procedure.
5. Scrub practitioner not checking blood loss.
6. Large number of staff in and out of theatre during procedure.
7. Anaethestic doctor went for a break just before Victoria was extubated.
8. The surgeon did not inform his consultant of the bleed.
9. Post-op notes were not properly reviewed.
10. No record of blood loss on the theatre care plan.
11. Uncertainty surrounding the handover of blood loss information from theatre to nursing staff.
12. Missing information on handover notes from recovery to ward nurses.
13. Missing information was not handed over when ward nurses changed shifts.
14. Victoria’s respiratory rate was only counted on every second set of observations by recovery nurses.
15. A staff nurse did not delegate post-op observations when she was called away, leaving a two-hour gap in monitoring.
16. The surgeon did not report the artery damage or blood loss during surgery to ward staff.
17. Routine post-op observations were discontinued.
18. No standard handover routine between day and night shift surgical doctors in place.
19. A junior doctor did not check Victoria’s haemoglobin result after her surgeon ordered tests.
20. Supervision of the junior doctor was not clearly defined.
21. The junior doctor did not examine Victoria’s abdomen while at her bedside – despite her complaining of pain in the area.
22. Inaccurate recording of medication.
23. The junior doctor did not make a note in Victoria’s records when he took a sample of her blood.
24. A staff nurse did not follow proper procedure when re-dressing an abdominal wound.
25. The same nurse disrupted an intact dressing too soon after surgery.
26. Nurses did not complete a formal pain assessment despite increasing levels of discomfort.
27. Vital signs were not monitored before or after Victoria was given intravenous morphine.
28. Routine 2am observations was not completed.
29. A nurse performed a visual assessment of Victoria in the dark without using a torch.
30. Improper overnight monitoring.
31. Poor observation of the patient.
32. Lights were switched on at 4.50 am – contravening hospital policy on patient well-being and dignity.
33. Lacked of piped oxygen to beds on the ward.
34. The primary staff nurse was not made aware of the bleed in theatre.
35. Blood tranfusion policy was not followed.
36. A scribe was not present during resuscitation attempts.
37. Only two people performed chest compressions during attempts to revive Victoria.
38. The primary staff nurse did not remain at Victoria’s bedside during resuscitation.
39. Unprofessional conduct by staff, who appeared ‘visibly distraught’ while colleagues tried to revive Victoria.
40. and 41. They attempted resuscitation was documented inaccurately.
42. No record of cardiac arrest and subsequent death in the patient’s nursing record.
43. No record made of discussions with relatives after Victoria died.
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