Spelling mistake at Northwick Park Hospital leads to grandmother, 85, bleeding to death
11:19 01 February 2016
A spelling mistake and a mix-up by senior medics led to a grandmother bleeding to death after an operation at Northwick Park Hospital, an inquest has ruled.
The blunder meant cross-matched blood supplies which were put on hold for Irmgard Cooper, 85, had been sent back to the bank resulting in a two-hour wait for a life-saving transfusion she needed.
By the time the replacement supplies arrived Mrs Cooper, who lived in Hayling Island in Hampshire, had lost all her blood and she died on the operating table.
On Friday at North London Coroner’s Court an inquest heard her name had been spelt as ‘Irngard’ instead of ‘Irmgard’ which resulted in the fatal delay.
In addition the surgeon had not been told no blood supplies were available during the operation until he was carrying out the procedure on May 7 last year.
The German-born mother-of-two, who had three grandchildren and had been married to husband Raymond for 62 years, had undergone a serious but successful operation to repair a large bulge in the main artery to her heart.
When the surgeon questioned the anaesthetist as to why he wasn’t giving extra blood supplies when needed, he was told for the first time that none were available.
She would have survived if her O negative blood supply was available in the theatre immediately.
Coroner Andrew Walker found gross failings in the failure to provide blood at a critical time when it was already previously known that blood would be required.
The inquest also found that the death was avoidable and she had died from neglect.
A Serious Incident Investigation Report subsequently conducted by the hospital found that she died from serious blood clotting difficulties, cardio vascular collapse, haemorrhage, and that the delay in giving blood caused her death.
Mrs Cooper’s daughter, Lorraine Booker, plans to sue London North West Healthcare NHS Trust over her mother’s death.
She said: “My father has suffered from nightmares over my mother’s death ever since. We just feel very let down and betrayed by the hospital for a death that should never have occurred.”
Renu Daly, from medical negligence specialists Hudgell Solicitors, who is acting on behalf of the family, said: “The first error was the mis-spelling of the patient’s name on the blood sample. The lack of communication between the anaesthetist and the surgeon over the absence of blood was the second error.
“Mrs Cooper was effectively dead from the time she arrived in intensive care, she was already suffering from catastrophic internal bleeding which meant death was inevitable.
“The family is now receiving our support and advice as they want to be certain that this matter is publicly investigated and exposed, and that devastating errors such as these are never able to happen again.”
Jacqueline Docherty, chief executive of the trust, said: “I would like to offer my sincere condolences to the family of Irmgard Cooper and say how sorry I am for what happened.
“We accept the coroner’s verdict. Prior to the inquest, the trust undertook a full internal investigation, and has implemented systems to ensure that incidents of this nature do not occur again.”