Rare complication led to death of grandmother
PUBLISHED: 06:30 17 July 2015
A Budleigh grandmother died from a rare complication as doctors investigated a suspected tumour in her lung, an inquest has heard.
Dot Gill, 74, of Sherbrook Close, died at the Royal Devon and Exeter Hospital on April 22 last year, having undergone a biopsy to check if the suspected tumour was malignant.
She died of a cardiac air embolism, which occurs as a result of air entering the bloodstream.
The inquest at County Hall heard that Mrs Gill had been recommended for surgery, but after a surgeon judged her to be high risk, she was first sent for the biopsy to confirm if the suspected tumour was malignant before the operation.
The biopsy was carried out by radiologist Professor Anthony Watkinson, who inserted a needle and collected two samples, after the first was deemed unsatisfactory.
He told the inquest that around 30 seconds after the procedure was finished, Mrs Gill sat up and coughed up some blood, which was not uncommon, but then ‘lost consciousness very quickly’ and doctors were unable to revive her.
Professor Watkinson told the inquest that he performed between four and six such procedures a week, and had never come across an air embolism before.
He said that, since Mrs Gill’s death, the hospital had reviewed its procedures, and changed its patient information leaflet to include more rare complications such as air embolism.
Professor Watkinson also said that, during the procedure, Mrs Gill had cleared her throat, and that now patients were advised that if they coughed during the procedure ‘it would probably be stopped at that point’, but added that there were reported cases of air embolisms where patients had not coughed, so it was not known how significant this was.
Recording a narrative conclusion - a factual statement of the circumstances surrounding someone’s death, without attributing the cause to an individual - Lydia Brown, assistant coroner for Exeter and Greater Devon, said Mrs Gill’s death had been due to ‘a recognised but rare complication of a planned surgical procedure’.
The coroner said: “It is not as though there was some sort of failure or difficulty at the time, just a recognised complication of the sort that statistically seems so seldom until they come into appalling technicolour when it’s one of your own.
“Nobody wants to be the five per cent, the one per cent, but they can and do happen.
“This was clearly a rare complication and the hospital has done a lot of work to make sure it’s not any of their techniques.”
Speaking after the inquest, Mrs Gill’s husband, Peter, said: “I hope what has been found out from this may prevent it happening again.
“If they learned something, hopefully someone else won’t go through the same circumstances.”
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