Coroner to raise concern with hospital

By James MortlockA CORONER is to write to a hospital after a woman died hours after her oxygen tube was found disconnected from its cylinder.Greater Suffolk coroner Dr Peter Dean will ask for training and procedures at West Suffolk Hospital in Bury St Edmunds, to be reviewed following the death of Monica McIntosh.

By James Mortlock

A CORONER is to write to a hospital after a woman died hours after her oxygen tube was found disconnected from its cylinder.

Greater Suffolk coroner Dr Peter Dean will ask for training and procedures at West Suffolk Hospital in Bury St Edmunds, to be reviewed following the death of Monica McIntosh.

But he stressed there had been no neglect or lack of care leading to the death of the 61-year-old retired legal secretary from St John's Close in Mildenhall.


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Dr Dean said Mrs McIntosh, who suffered a brain haemorrhage which was not confirmed by tests at the hospital for more than a week, died as the result of “recognised complications following necessary” life-saving brain surgery at the area's specialist neurology unit at Addenbrooke's Hospital, Cambridge.

He added the haemorrhage had gone unconfirmed for several days, even though Mrs McIntosh's GP strongly suspected she had suffered a bleed in her brain.

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However, Dr Dean stressed staff at the West Suffolk Hospital, who feared she had contracted bacterial meningitis, had done everything they could to help her.

Recording a narrative verdict, Dr Dean said he understood the concerns of Mrs McIntosh's family.

“They felt things deteriorated without it (the bleed) being addressed. They feel the signs were evident and appropriate treatment should have been given,” he added.

“But it's clear from the evidence that a haemorrhage was considered from the outset and appropriate tests carried out. She had a CAT scan and lumber puncture and they both failed to show the haemorrhage.

“The hospital didn't stop looking for the cause of the underlying problem. There is no suggestion of any gross failure to provide appropriate care.”

Dr Dean said although the loose oxygen pipe, spotted only hours before Mrs McIntosh died at the West Suffolk Hospital in March last year - five months after she suffered the bleed at her home - was concerning, it had no bearing on her death.

He added Mrs McIntosh had been brought back to Bury St Edmunds from Addenbrooke's Hospital to die.

But Dr Dean told the Bury St Edmunds inquest yesterday: “I am happy to write to the hospital to ask that training in this area is reviewed.

“It's regrettable that the incident with this tubing happened and everything must be done to stop it happening again to prevent a tragedy happening.

“But I stress that in no way does my writing imply liability. It's purely to prevent fatalities in the future.”

Speaking after the inquest, a spokesman for the hospital, which conducted its own investigation following the incident, said: “The inquest concluded a verdict of recognisable complications following necessary medical treatment.

“Neglect played no part in her death. The hospital trust is very sorry that Mrs McIntosh died and we would like to extend our deepest sympathies to her family.”

In a statement read to the inquest, Mrs McIntosh's husband Alexander said his wife's condition had deteriorated about a week after she was taken by ambulance to West Suffolk Hospital. She suffered a second brain haemorrhage and went into a coma.

He said: “It wasn't until this point that West Suffolk Hospital staff realised that drastic action was needed and a bed was found at Addenbrooke's.”

Dr Graham Lennox, consultant neurosurgeon at Addenbrooke's Hospital, told the inquest it was the operation which had caused the damage to Mrs McIntosh's brain.

“You're dealing with a very fragile structure. It was the operation, in my view, which caused the damage. I don't think the complications could have been avoided,” he said.

A post-mortem examination found Mrs McIntosh had died of a brain abscess caused by the haemorrhage.

Pathologist Dr Barry Cottrell stressed: “In my opinion, the short period of time when she had low oxygen (as the result of the tube coming loose) did not contribute to her death.”

Speaking after the inquest, Mrs McIntosh's daughter, Alison, said she was unhappy with the verdict.

james.mortlock@eadt.co.uk

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