A PENSIONER died after doctors at Scarborough hospital failed to notice a fatal error had occurred during an operation to install a pacemaker.
Doreen Gullen, of Moor Lane in Newby, was admitted to hospital in January this year after suffering a fall due to ‘sick sinus syndrome’.
The 82-year-old was told she had to be fitted with a pacemaker to restore the rhythm of her heart and prevent future falls.
However her operation on January 11 had to be aborted after four failed attempts by two doctors to fit a wire in to Mrs Gullen.
Sadly neither doctor had noticed that during one of those attempts the wire had pierced a hole in one of her arteries.
During her inquest coroner Michael Oakley heard that by the time the tear was identified doctors could not locate the hole in time to save Mrs Gullen’s life.
Speaking at the inquest Dr Muhammad Anwar Memon, the cardiologist who carried out the operation, said he was very sorry and he felt “as if my own mum had died”.
Dr Memon told Mrs Gullen’s family, who attended the inquest, that since her death procedures have changed at the hospital in relation the pacemaker operations.
He said all operations will now be aborted after two failed attempts, then the patient will be seen by a radiologist.
Dr Memon said it was quite common for arteries to tear during the procedure, but he had never in his career known of a tear going unnoticed.
During the inquest Mrs Gullen’s son Raymond raised concerns about the length of time it took from doctors first realising there was a problem, to sending her for a scan to identify it.
His fears were supported by the coroner Mr Oakley who asked Mr Memon: “Why did it take such a long time? You first realised something was seriously wrong at 3.30pm but she didn’t have her scan until 5pm.
“If you had someone come in to A&E who has had an accident the crucial treatment time is in the first few minutes. This should be the same in a procedure.
“It seems to me and to Mrs Gullen’s family that it was quite a long time waiting an hour and a half.”
Dr Memon said he will take the issues raised back with him and work on improving it.
After hearing the evidence Mr Oakley recorded a verdict of misadventure.
Following the inquest a spokesperson for Scarborough and North East Yorkshire Healthcare NHS Trust said: “We offer our condolences to Mrs Gullen’s family. This was a very rare complication, however we have reflected on our practice since Mrs Gullen’s death and will continue to do so to identify any areas where improvements can be made.”