Health chiefs say sorry for Marlene Wightman 'failings'

HEALTH chiefs today apologised "unreservedly"for the "major failings" in its care which left a woman to bleed to death following breast cancer surgery.

The death of Marlene Wightman, 49, was "entirely preventable", Sheriff Isabella McColl ruled following a fatal accident inquiry yesterday.

Staff at the Western General Hospital are now facing the threat of disciplinary action while an internal investigation is carried out by the health board.

Today Charles Swainson, medical director of NHS

Lothian, said: "Our concern is that there were major failings in organisation. It's not about blaming individual members of staff.

"We have several times apologised unreservedly to her family. I think it's clear there have been major failings in looking after Mrs Wightman."

The mother-of-two, from Dalkeith, bled to death in the early hours of 23 March 2006, the day after a mastectomy operation.

Her death has led to damning criticism of the procedures in Ward 6 of the hospital in the sheriff's written determination of the case.

Staff with little experience in breast surgery aftercare failed to identify she was haemorrhaging or transfer her to a high dependency unit until it was too late to save her life.

The hospital failed to provide enough training to nursing staff and junior out-of-hours doctors.

Sheriff McColl also criticised records which were "incomplete and contained inconsistencies, inaccuracies, alterations and errors".

She also hit out at the "fairly appalling treatment" of Mrs Wightman's husband Tom, and two children, by the hospital. He was given little information when he was called to the hospital late on the night she died, with no-one offering a reasonable explanation of why he needed to be there until after his wife's death.

The family were left in a room on the ward, where they could see staff fighting to save Mrs Wightman's life. The sheriff said the hospital had also been reluctant to provide information and records following her death.

During the inquiry, surgeon Michael Dixon, who carried out the mastectomy, said he could have saved Mrs Wightman's life if he had been told about her worrying blood loss. When he spoke to the family the day after her death, he appeared extremely upset and said the operation had been fine, but the aftercare was at fault. He told them he could see someone bleeding to death outside a hospital, but not inside.

Evidence from Professor Alistair Thompson of Ninewells Hospital, Dundee, 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.

Today, Mr Swainson added: "We've already put into place the majority of the recommendations, in particular the proper education and induction of nursing staff and junior doctors covering the unit, so they understand what to look out for. I think everybody has learned from the incident."

The health board has now introduced audits to ensure accurate records are kept. From next year, the ward will also become a dedicated breast treatment ward.

Elaine Motion, of Balfour & Mason LLP, the solicitor advocate for the Wightman family, acknowledged that the hospital had taken some steps to remedy the failures, but said there was still much to be done.

She said: "The family have sat through a trial for almost a year listening to evidence which was awful, and they did it with such dignity. To hear that her death was "entirely preventable" was expected, but still devastating.

"They desperately hope that the hospital will make the changes required to ensure this never happens again."