ISSUES with hospital treatment contributed to the death of a pensioner, a coroner has ruled.
Alice Porter suffered a heart attack while doctors tried to drain excess fluid from around her heart at Sunderland Royal Hospital, in April 2009.
The Ryhope 77-year-old suffered brain damage and died the next day, a seven-day inquest at the civic centre was told.
Mrs Porter, who lived in Queen Street with husband Thomas, was taken to the hospital after complaining of shortness of breath on April 4.
A heart scan showed an abnormal build-up of fluid between the heart and the sac around it.
Three days later doctors attempted to drain the fluid in a procedure known as a pericardiocentensis, so a sample could be sent off for analysis.
But shortly afterwards, Mrs Porter suffered two heart attacks.
Consultant cardiologist Dr Mohsen Gaballa made two attempts to drain the fluid, one without x-ray or scan to guide him, as CPR was being carried out on Mrs Porter.
But after taking off nearly a litre of fluid without reducing the build-up, it was decided the drain was not correctly placed. Too ill to be transferred to Newcastle’s Freeman Hospital for heart surgery, Mrs Porter was admitted to the Royal’s critical care unit with both drains still in place.
An entry on her care notes by Dr Andrew Morrison, on the instructions of Dr Gaballa, ordered the drains be opened and closed at three-hourly intervals.
Dr Morrison admitted at the hearing he had reservations about this, because the misplaced drain would be draining blood from the circulation, not the fluid around the heart.
However, he deferred to the specialist knowledge of the cardiologists.
By 8.30pm, doctors decided Mrs Porter would not survive and her family gave permission for treatment to be withdrawn. She was pronounced dead at 2.25am on April 8.
City coroner Derek Winter ruled out a verdict of gross negligence manslaughter.
Summing up the findings, he said: “The evidence supports my finding that the pericardiocentesis procedure was implicated in Alice’s death and also if the drain had been left closed, then the blood loss would essentially have stopped and Alice would not have died of the cause she did at the time she did.
“Whilst it is not possible to say how much brain damage Alice had sustained, it was likely to have been significant after a cardiac arrest of the duration described to me. However, it was not ultimately the cause of death nor did she bleed to death.”
Home Office pathologist Dr Stuart Hamilton told the hearing that one of the catheters had passed into the left pulmonary artery of the heart. He gave the cause of death as penetration of the heart during pericardiocentensis procedure.
Verdict: Ms Porter died from complications arising from the procedure, contributed on occasions by a failure to formulate, document, communicate, co-ordinate and implement a clear care plan appropriate to her needs.