THE death of a 49-year old woman following breast surgery in Edinburgh's Western General Hospital was "entirely preventable".
Marlene Wightman bled to death in the early hours of 23 March, 2006, the day after a mastectomy operation. At under five feet tall, Mrs Wightman weighed just seven and a half stone.
Her death has led to damning criticism of the procedures in Ward
6 of the hospital by Sheriff Isabella McColl in a written determination issued today (Nov 6) following a Fatal Accident Inquiry at Edinburgh Sheriff Court.
The Sheriff said reasonable precautions that might have prevented the death included earlier diagnosis that she was haemorrhaging; transferring her to a high dependency unit for a minimum of 24 hours after her surgery; and training and guidance having been provided to nursing staff and junior out of hours medical staff in relation to volumes of blood in drains of patients who had undergone such surgery.
Defects in procedures which contributed to Mrs Wightman's death were a failure to provide an adequate system of induction and education for nurses and junior medical staff; a failure to provide on-site out of hours medical cover with staff who had adequate experience or training; and a failure to have a system of handover from the breast surgery medical staff to the junior house doctor on call for Ward 6 or to the Hospital Night Team.
The Sheriff also hit out at the records being kept about Mrs Wightman stating they were "incomplete and contained inconsistencies, inaccuracies, alterations and errors". Ward 6, she added, lacked adequate practical oversight and management.
Sheriff McColl said the treatment of Mrs Wightman's family at the hospital had been "fairly appalling".
Her husband, Tom, received a telephone call at 11.50pm, telling him to come to the hospital immediately. He did not know who the person was and was not given any information as to why. He was taken to a room in Ward 6 and left. His son, John and daughter, Lisa, arrived shortly afterwards. They could see people working on their mother. At half past midnight, they were told Mrs Wightman had died. At 2am, the on-call surgeon, Mr Glyn Neades, met the family and said he was sorry and expressed sympathy. He offered no further information.
Mr Wightman phoned the hospital later in the morning and said he wanted to come in and speak to someone about his wife's death. He was asked why he felt that was necessary and was told to call back later. The family were then told to come in after ten o'clock. When they did they were out in the same room where they had witnessed the efforts to save Mrs Wightman's life.
While they were there, Mr Michael Dixon, the surgeon who had carried out the mastectomy came to see them. He was extremely upset and told the family he could see someone bleeding to death outside a hospital, but not inside. He said the operation was fine, but the aftercare was at fault. He advised the family to employ a lawyer.
Sheriff McColl said the poor relationship between the hospital and family continued with reluctance by the hospital to provide information and records. "The hospital has no doubt been acting on legal advice" said the Sheriff "but there must be a better way to treat people who have been so suddenly and shockingly bereaved".
Evidence from Professor Alistair Thompson of Ninewells Hospital, Dundee, called by The Crown as an expert witness, was that if Mrs Wightmam had not died she could have looked forward to at least an 82 per cent chance of surviving for ten years after her surgery.
Elaine Motion, solicitor advocate, for the family, acknowledged that the hospital had taken some steps to remedy the failures identified by the Inquiry, but said there was still much to be done. "The family would welcome an unreserved acceptance of the recommendations of the Inquiry and the assurance that all parts will be fully implemented immediately."
In a statement, husband, Tom, son, John and daughter, Lisa, described their wife and mother as "The heart and soul of our family".
"We have lived our lives for nearly four years since Marlene passed away, hoping that one day we would wake from what is the worst possible nightmare. Not a day goes by without us remembering her".
Their statement added: "It pains us deeply to have heard during a very lengthy Fatal Accident Inquiry over the course of a year that Marlene was suffering for hours before anyone realised she was deteriorating. When her deterioration was finally recognised it was too late to save her. Marlene fought for a long time to stay alive, but was failed by the system that so many of us put our trust in".
The family, from Dalkeith, added that they asked to be left in peace to grieve and that their wishes be respected.
