Coroner slams hospital's 'total failure' after woman, 64, dies after routine knee op

Jennifer Fisher, described as a fit and active 64 year-old, died at her home in Scarborough, on January 23 after having a knee arthroscopy at Bridlington Hospital less than two weeks earlier.

At an inquest at Scarborough Coroner's Court, the cause of death was given as a pulmonary embolism brought on by deep vein thrombosis (DVT).

Mrs Fisher, a grandmother-of-six, was given no chemical or physical treatment to prevent the onset of DVT even though she had previously been treated for phlebitis as well as varicose veins - meaning she was predisposed to the condition.

Coroner Michael Oakley said that the failure to provide chemical prophylaxis prior to surgery or TED compression stockings, which are routinely provided to patients, could amount to negligence.

Recording a narrative verdict, Mr Oakley said: "The hospital have totally failed this lady and I am just getting a little bit upset, and the family will be very upset, at the number of cases I am encountering where things like this are occurring. I do not understand why this has been allowed to happen.

"I will be writing to the hospital trust's chief executive and want to know why chemical prophylaxis is not routinely given to patients. I have been told by several eminent surgeons that unless there are medical reasons not to do so, this would amount to negligence. Not only has that not happened but the TED stockings weren't supplied either."

Children Samantha, Peter and Lucy said that their mother's death had "left a devastating hole in all of our lives".

In a statement read out to the court, Peter Fisher said his late wife: "had always been fit, active, quite sporty and enjoyed badminton and tennis."

However she began to experience problems with her right knee last summer, and after a consultation with orthopedic surgeon, she decided to have surgery to repair a torn cartilage.

Mr Fisher said his wife had made sure hospital staff were aware of her previous problems with blood circulation and had remarked after the surgery that she had not been given compression stockings, which are designed to prevent blood clots, despite them being provided to two other patients who had similar procedures.

Mr Fisher described how on the morning of January 23 his wife got up and had breakfast, before complaining of dizziness and shortness of breath. She lay on the bed and said she needed a doctor, before smiling at her husband and 'drifting to sleep' - tragically she never regained consciousness.

Giving evidence, Dr Evans admitted that he did not routinely read patients' full medical records before performing surgery, instead relying on information in the GP's referral.

He added that it was "not necessarily the case" that all patients should be given a chemical prophylaxis for procedures lasting under 30 minutes, and insisted he had followed National Institute for Clinical Excellence (NICE) guidelines.

Although Mrs Fisher should have been given TED stockings, he said passing them to patients was "typically a nursing duty".

After the verdict, Mr Fisher and his daughter Lucy said they were happy with the coroner's comments, but remained angry with the hospital.

Lucy said: "They failed in my mother's basic care. She got so much enjoyment out of life and all of that has just been taken away from everyone."

A spokesperson for Scarborough and North East Yorkshire Healthcare NHS trust said: "We would like to express our sympathy to the family of Jennifer Fisher and are sorry for their sad loss.

"All the people involved from the hospital have cooperated fully with the coroner's investigation. We note the coroner's verdict following the inquest and will be taking his comments very seriously.

"We would like to reassure our patients that our approach to this type of operation has changed across the Trust and all staff are following new NICE guidance in orthopaedics."