Coroner criticises Northamptonshire Hospital’s failures after teenager dies following routine appendix surgery

Posted: 11/12/2013

Northhamptonshire coroner, Ann Pember has said that crucial opportunities were missed to save a Northamptonshire teenager following routine surgery to remove her appendix. Victoria Harrison, 17, underwent the keyhole operation on 15 August 2012. During surgery an artery was torn but staff failed to act upon warning signs. Miss Harrison suffered substantial blood loss and was found unresponsive the next morning.

Ms Pember said that Miss Harrison’s chances of survival would have significantly increased had opportunities to treat her not been lost. She said it was possible a deterioration would have shown had she been regularly monitored. 

Miss Harrison, a beautician from Irthlingborough, Northamptonshire, known as 'Tor', had been referred to the hospital by her GP with suspected appendicitis. The surgeon performing the procedure, Shady Hosny, told the inquest he rectified the bleed and that Tor had lost 200ml of blood during surgery, with 50ml being the norm. The operation was thought to be a success and Tor was returned to the ward, the hearing was told. She was found pale and unresponsive by a care assistant at 5:30am the following day and tragically failed to respond to resuscitation. 

Nurse Gillian Joy gave evidence to the inquest that nursing staff did not routinely read medical notes and often could not decipher a surgeon's handwriting.

Ms Pember gave a narrative verdict, stating: "There was a poor handover from theatre staff to the recovery nurse and in turn to the ward staff, in particular concerning the bleed which had occurred and been rectified in surgery. There was a failure to carry out appropriate post-operative observations. Tor's last written formal observations were at 8.15pm. There was a further failure to conduct a formal observation following the introduction of morphine.

"Had Tor's observations been monitored at regular intervals, including pulse and blood pressure, it is possible that deteriorating trend may have been recognised. Windows of opportunity to treat Tor were lost. Had these been acted upon the outcome may have been different. I believe her chances of survival would have significantly increased."

After the inquest Miss Harrison’s mother, Tracy Foskett, spoke of her grief: "A mother shouldn't lose her child. I've lost my best friend."

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