Series of ‘absences’ contributed to Barkingside woman’s death, third inquest rules
PUBLISHED: 10:29 04 October 2016 | UPDATED: 12:16 04 October 2016
A series of medical “absences” played a part in the death of a woman who died after a routine kidney stone operation, a coroner has ruled, at the end of the third inquest into the death.
Carmel Bloom, 54, of Fremantle Road, Barkingside, died on September 8 2002, after surgery at the private Roding Hospital in Redbridge, run by Bupa at the time, where she worked as a health controller.
She was taken to Whipps Cross intensive therapy unit (ITU) and died after her blood pressure fell and she suffered cardiac arrest.
This new inquest into the circumstances of her death was ordered in 2014, after her family said fresh evidence, including an expert report and a 999 call where the night sister at the private hospital is describing the seriousness of Carmel’s condition to emergency services, should at last give a full picture of how she came to die.
Coroner Karon Monaghan QC, of West London Coroner’s Court sitting at the Royal Courts of Justice, dismissed arguments for unlawful killing.
She said: “Carmel Bloom’s death was contributed to by the absence of regular monitoring, the absence of timely communication between nursing staff and the consultant urological surgeon, the absence of timely communication between the consultant urological surgeon and consultant anaesthetist, and the absence of intubation and ventilation prior to transfer from Bupa Roding Hospital to Whipps Cross ITU.”
After her procedure on August 28, Ms Bloom was returned to the ward, but her blood pressure began to fall in the early hours of the next day.
The consultant urological surgeon telephoned staff and gave instructions about her ongoing care - including half-hourly observations - but her condition deteriorated and her “vital signs were not consistently recorded”, the coroner said.
Ms Bloom’s blood pressure continued to fall and by 2am she was septic, but the consultant urological surgeon was not called until 2.55am and arrived 20 minutes later.
The consultant anaesthetist was not called until 4.29am “by which time” Ms Bloom was suffering from pulmonary oedema, the coroner said.
She was rushed to Whipps Cross intensive therapy unit (ITU).
The coroner said: “The consultant anaesthetist did not intubate and ventilate Carmel Bloom before transferring her, or attach equipment which would have allowed for the monitoring of her vital signs during transfer.
Shortly after her arrival Ms Bloom went into cardiac arrest, experiencing severe brain injuries. She did not regain consciousness.
She remained on life support until September 8 when the decision was taken to turn the machine off.
She died after her blood pressure fell and she had another cardiac arrest.
The first inquest in 2003 found Ms Bloom died of natural causes, but that verdict was quashed by the High Court in December 2004.
The second inquest in 2005 at West London Coroner’s Court found lack of post-operative care contributed to her death.
That finding, deemed inadequate by the Bloom family, was also quashed.
After delivering the ruling, the coroner turned to Ms Bloom’s brother Bernard, and passed on her condolences.
She said: “I hope that this inquest has given you the opportunity for some of your questions to be answered.”
After the hearing Mr Bloom said: “Carmel was let down and the system has badly let down the family.”
He said: “This has taken over 14 years. I could not have done this any quicker.
“It was bad enough what happened to Carmel, but what happened to the family, it is a disgrace. It is the system that needs to be amended.”
A Bupa spokeswoman said: “We sympathise with Carmel Bloom’s family for their loss.
“Her colleagues at the hospital were all deeply affected by this tragic incident in 2002.
“As we no longer own the hospital, it’s not appropriate for us to comment any further.”
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