Tests might have saved mother, inquest is told

Tracy Hall, 38, of Castleford suffered multi-organ failure caused by blood poisoning but there was a possibility she might have survived , the hearing at Leeds Coroner’s Court heard.

Mrs Hall died on May 12, 2009, at Pinderfields Hospital, Wakefield.

Mary Burke, Assistant Deputy Coroner for Leeds, recorded a narrative verdict saying Mrs Hall died due to multi-organ failure caused by septicaemia, or blood poisoning and small bowel death.

Mrs Hall suffered from Crohn’s disease, a condition which causes the chronic inflammation of the digestive system and, the court heard, was anxious, bordering on “pushy”, to be operated upon.

She underwent surgery on April 28, 2009, to repair scarring to her abdomen but it did not heal as expected and she spent several days in hospital as medical staff tried to find the source of her problems.

At an earlier hearing, the court heard evidence from independent medical expert Professor John Northover, who said doctors treating Mrs Hall on May 4, 2009, at Pinderfields Hospital could have acted quicker by carrying out blood tests to help diagnose her condition.

The tests would have backed up a scan which showed she was suffering from internal bleeding and, therefore, further surgery was needed.

Anna Bosley, a medical law expert at Irwin Mitchell, who represents Tracy’s mother Carol Harris added: “The family desperately needed answers as they believed more could have been done in Tracy’s care.

“The inquest has highlighted that further tests could have been carried out earlier to help diagnose her condition and earlier treatment may have led to her surviving.

“Incidents such as this highlight important lessons which need to be taken on board and we hope that Pinderfields Hospital ensures that others do not suffer from similar circumstances in future.

“Patient safety should be the number one priority for the NHS but it appears that sadly, Tracy was let down on this occasion.”

The court heard Mrs Hall had undergone surgery in 2008 where it was discovered she required a colostomy bag to control the damage the disease had caused to her large intestine.

On April 28, 2009, she was admitted to Pinderfields Hospital to allow doctors to reverse the procedure and to carry out some reconstructive surgery on the scarring to her abdomen.

Over the next few days doctors observed she was not healing as well as anticipated and she was taken into surgery to investigate the wound.

Her abdominal wound split on May 4 and she was again taken back to surgery. Doctors could not find any evidence of septicaemia or bleeding and she was admitted to the high dependency ward.

A day later her blood results showed abnormalities and she was given a blood transfusion. A scan showed internal bleeding and she was taken back to theatre for further investigations.

No signs of septicaemia were discovered and she was admitted to intensive care.

During the next few days, however, her condition deteriorated rapidly and she developed septicaemia and died on May 12.

Prof Tim Hendra, medical director at The Mid Yorkshire Hospitals NHS Trust, said: “We would like to offer our condolences to Mrs Hall’s family for their sad loss.

“Mrs Hall’s condition was complex. Following her death we carried out a thorough investigation into her care to learn lessons and make improvements.

“We will use the findings of the inquest to determine if there are further improvements that need to be made.

“We understand Mrs Hall’s family are currently pursuing a legal claim and we are fully co-operating with that process.”

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