Husband's heartache at wife's death following operation blunders
PUBLISHED: 17:37 16 January 2020 | UPDATED: 22:44 16 January 2020
The husband of a Bury St Edmunds woman who died after complications with her hospital treatment says he does not want another family to go through the heartache they have endured.
Susan Warby, known as Sue, died at West Suffolk Hospital in Bury St Edmunds, on August 30, 2018, after 35 days in hospital, including two rounds of bowel surgery, having been admitted with abdominal pain, vomiting and diarrhoea.
An inquest in Ipswich heard that following her death husband Jon Warby, a retired police officer, received an anonymous letter from a whistleblower "suggesting something had gone wrong during the surgery".
Coroner Nigel Parsley said because of the letter, which said the wrong intravenous fluid had been used, he asked Suffolk police and the hospital to conduct their own investigations, both of which confirmed the issue with the arterial line.
A check found Mrs Warby had incorrectly been given glucose instead of saline.
Mr Warby said: "I asked what the effect of this could be and the consultant told me brain damage or death."
Doctors were reportedly asked for fingerprints as part of the hospital's investigation, with an official from trade union Unison describing the investigation as a "witch hunt" designed to identify the whistleblower who revealed the blunders.
In a statement, Mr Warby, who now works as a delivery driver, said his wife's death had been a "very distressing time" not just for himself and her sons, but all their families.
He said the effect of the errors during her time in hospital hindered her ability to recover.
"I do not understand how or why any of these incidents happened and while I have nothing but praise for some nursing staff that cared for Sue I want to know why," he said.
"Nobody should have to go through what we went through," he added.
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West Suffolk Hospital manager Paul Morris told the inquest a report had found no evidence the mix-up of glucose and saline had an impact on the outcome in Mrs Warby's case.
But he said action has been taken following her death, including additional checks to help ensure the correct fluid is used from the theatre storeroom, improved checks at the bedside and new fluid bags have been introduced with clearer labelling.
"We know Mrs Warby was very unwell but we know there are things that did go wrong in her care," said Mr Morris.
"We think it's unlikely to have been the sole cause (of her death) but she was very unwell."
The inquest also heard one of Mrs Warby's lungs had been perforated during a procedure to insert a central venous catheter.
Mrs Warby's medical cause of death was recorded as multi-organ failure, with contributory causes including septicaemia and an infection due to a perforated bowel.
The inquest heard Mrs Warby had complained of abdominal pain and diarrhoea for about a fortnight before she collapsed at home on July 26, 2018, and her husband called the NHS 111 number.
She was taken to hospital by ambulance and underwent emergency open surgery the following day for a perforated bowel.
The inquest heard Mrs Warby was too unwell for her surgical incisions to be stitched up after the surgery and this was eventually done on July 29.
She had previously been diagnosed with the digestive condition diverticular disease in 1997.
Consultant surgeon Dr Amitabh Mishra, who operated on Mrs Warby, said: "Given how unwell she was, it was decided to proceed directly to an open operation."
He said she was assessed as having an 84.8% risk of mortality, taking into account her underlying factors including her hypertension and that she was a smoker.
The inquest, listed for two days, continues.