The family of 14-year-old girl who died during an over-stretched hospital night shift have called for more NHS staff to be on duty around-the-clock.
Tragic Emma Welch underwent an apparently successful operation to correct a curvature of her spine just days after undertaking a charity walk up Mount Snowdon.
But the following night she suffered an internal bleed which triggered a fatal heart attack and she required emergency surgery.
However, just two of nine operating theatres at Bristol Children’s Hospital were open at the time because it was late at night – and they were both in use.
There were not enough anaesthetists or emergency staff to open another theatre so medics had to operate on her by torchlight on a ward.
Doctors battled through the night to try and replace the blood she was rapidly losing but she tragically died at 3.42am on June 4.
A report into her death said it was probable that if she had been taken to theatre an hour earlier the bleeding could have been controlled.
Emma‘s mother, Lesley Welch, 51, and other family members are now pushing for 24-hour care in the NHS.
Anthony Close, Emma‘s grandfather, said: “Without there being an available theatre, emergency chest surgery on Emma had finally to be performed in her hospital bed with the help of torch light.
“We appreciate all that the staff did to the best of their abilities to try and save Emma and we know that such a traumatic experience must have affected them deeply.
“However, unanswered questions still remain and we will vigorously pursue these.”
He added that they hope a plan is put in place to provide additional theatre capacity and teams to cover emergencies, day and night.
The inquest heard that the youngster had undergone a routine operation to correct her spine which had been painfully curved for four years.
It appeared to be a success at first but the following night she suffered the internal bleed which drained her heart and triggered a fatal heart attack.
Just four days before she died the kind-hearted youngster had defied her spinal problem and agonising pain to climb Snowdon on a charity walk.
Helped by her parents, she set a world record for carrying the 125 cuddly toys to the top of a mountain after trekking to the 3,500′ summit of the Welsh peak.
Before that she had climbed the height of Everest on a climbing wall in 2013 and cycled 1,000 miles in 2014 to raise £13,000 money for Brain Tumour Research.
Her family heard she might have lived if she been rushed straight to an operating theatre as soon as her post-op problem was detected.
The inquest at Avon Coroner’s Court at Flax Bourton, near Bristol, heard that “manpower was the issue” in her case.
Consultant Dr Margrid Schindler, who cared for Emma in intensive care, said ideally she the teenager have been taken to theatre straight away.
She told the inquest: “The doctor went to theatre but the problem was we had our two emergency teams busy in theatre.
“There was no team available at that particular moment to get Emma to theatre any earlier.”
Hospital site manager Jane Hetherington said there was no way she could have opened another theatre because she would need a team of anaesthetists.
She said: “We could have gone and waited in an empty theatre but we wouldn’t have known where all the equipment was.”
Spinal surgeon Mr Ian Harding, who carried out the original procedure, said the team resorted to resuscitating Emma on her bed when her heart stopped.
But he disputed the claim she would have survived if she was taken to theatre earlier and said things would only be different if the problem had been identified more quickly.
He told the inquest: “If we had got her to theatre half an hour, an hour earlier, I think the outcome would have been exactly the same.”
Asked if Emma‘s life could have been saved, he said: “I think if we had known exactly what was happening straight away, from minute one, then yes.”
Mr Harding, who rushed to the hospital to care for Emma after being woken up at 1am, also said that the way her aorta was supposedly punctured was “completely unheard of”.
The most likely cause of death was a rod inserted during surgery being too close to the blood vessel or as the result of movement, a pathologist said.
Senior Coroner Maria Voisin concluded that Emma died “from the unintended consequence of planned and necessary medical treatment”.
She said she died ‘despite the efforts’ of receiving numerous blood transfusions and chest compressions.
The inquest heard that doctors around the world are currently researching how Emma, from Chilcompton, Somerset, could have suffered the post-op complication.
In an emotional statement read aloud in court, Emma‘s mother said her daughter was an “extraordinary girl” who had a “zest for life and making a difference”.
She said: “She was bright and bubbly – a girl who enjoyed sharing a smile and a laugh.”
“The impact of our loss is just too huge to begin to describe.”
Speaking after the hearing, she added: “If she had gone to theatre, there is a slim chance she would still be with us.”
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