EXCLUSIVE

MACCLESFIELD Hospital has been slammed for "systemic organisational failures" following a catalogue of errors leading up to the death of a "fighting fit" 71-year-old housewife.

A leading independent expert commissioned by coroner Nicholas Reheinberg called for a surgeon at the hospital to retrain for his part in the strict Catholic woman's flawed treatment.

And he urged an established medical check on patients to be closely followed in the future to prevent a reoccurrence - even insisting on supervised "dummy" practise.

The recommendations came at an inquest into the death of mum Gertrude Moss who caught MRSA and died from breathing complications after nurses and a junior doctor ignored warning signals, an inquest heard.

The series of blunders came after an operation to remove a suspected bowel tumour - six months prior to her death.

And they included, the inquest heard:

  • An experienced surgeon leaving a guidewire inside her while fitting "a central line".
  • A nurse wiping "an unpleasant discharge" from an infected area with the patient's own flannel.
  • A junior doctor said to regularly wear an iPod on his rounds, giving Gertrude's Catholic family an optimistic diagnosis; only for her to die the next day - Christmas Day - without receiving the last rites.

In recording a verdict of death by misadventure, Mr Rheinberg said: "The cause of death was directly related to the surgery Mrs Moss underwent, because in general terms she was fighting fit.

"I have been distressed to hear of wildly optimistic statements given to the family, particularly after hearing of Mrs Moss' strict Catholic faith."

Expert Dr Solomon Almond of the Royal Liverpool University Hospital, told the inquest that the East Cheshire NHS Trust needed to make changes at Macclesfield Hospital.

And he added: "I think there was a breakdown in the team approach."

He said: "In my opinion there are systemic organisational failures highlighted by this case.

"Two lessons have to be learned: responses to early warning is adhered to, and be very careful when observing doctors doing procedures."

American-born Gertrude Moss, of Robin Crescent, had surgery in July 7, 2005, in Macclesfield Hospital for suspected bowel cancer.

One day later a guidewire used to fit a central line to check fluids was left inside her, the coroner was told by Macclesfield surgeon Simon Ward.

The New York-born housewife was rushed to Manchester Royal Infirmary where the wire was removed - a procedure that can't be performed at Macclesfield Hospital.

Mr Ward, who was found to be blameless in the botched procedure, added that "the well-trained staff surgeon" who fitted the line was "utterly mortified" by what happened.

And referring to the "early warning" system, he said that doctors not certain about procedures were "mad" not to seek advice.

But expert Dr Almond concluded that leaving the wire in was "avoidable" and suggested that there "had to be something wrong with the technique". He said: "If that had happened then, there is a risk with that surgeon's other procedures."

He advised surgeons should be observed practising the procedures on a dummy.

Gertrude's widower, Lionel, 64, a retired driver, was too distraught to give evidence and had to leave the hearing during some of the evidence.

Her daughter, Ann Burgess, a nurse, of Southacre Drive, Macclesfield, told the coroner: "It was absolutely disgusting that my father was given optimistic information the day before my mother died. Why can't a trained nurse recognise the difference between an unconscious patient and a dying one?"

"I felt that the care she had when she first came back from theatre was appalling.

"I didn't think she was going to die."

Gertrude's younger daughter Mary, an airline training instructor, of Buglawton, Congleton: "I begged for someone to see my mother on the ward. This is clearly a lady going downhill rapidly.

"The junior doctor came and said she was doing quite well and my dad said, 'are you sure you have got the right woman, she's on 15 litres of oxygen and is out for the count'. I said this to the house officer and he apologised after my mum died."

Pathologist Dr Cerys Burrows gave the cause of death as adult respiratory distress syndrome.

A spokeswoman from East Cheshire NHS Trust confirmed it was investigating the events leading up to the death and the treatment of Mrs Moss.

She said: "We would like to convey our sincere condolences to her family. The trust welcomes the coroner's findings and will ensure that any lessons that may result from the review will be promptly actioned. The trust has offered to meet with the patient's family to discuss the findings of the review and the inquest."