Narrative verdict returned at inquest of man who went without oxygen for 25 minutes at Blackpool Victoria Hospital

A narrative verdict was returned by assistant Blackpool and Fylde coroner Louise Rae in the case of Graham Hargreaves, who died in Blackpool Victoria Hospital on January 4, 2020.

Mr Hargreaves, as retired accounts office worker from Rossendale had undergone the removal of right lung (right pneumonectomy) because it was cancerous, on December 30 2019 but despite the patient’s good progress, a further procedure was needed when he deteriorated.

After entering the anaesthetic room he died from a fatal cardiac arrest, five days after the initial operation.

Ms Rae found that a hypoxic brain injury, caused by the resulting lack of oxygen, was a contributory factor in his death.

However, pre-existing heart conditions were also included as ‘cause of death’ factors, with the inquest hearing Mr Hargreaves heart would have been under extra pressure because he had only lung.

Expert’s view on tube

It transpired that the pathologist who examined Mr Hargreaves after his death, Dr Mark Sissons, had been unaware of any issue in the anaesthetic room and had therefore not taken the brain injury into account, listing only cardiac arrest and his heart conditions as the causes of death.

However, the issues had come to light later, leading to the inquest at the request of Mr Hargreaves’ relatives.

On the final day of the three-day inquest at Blackpool Coroner’s Court in the town hall, Ms Rae accepted that the intubation tube had wrongly been inserted into Hargreaves oesophagus, causing oxygen to enter his stomach instead of lungs.

The intubation had been overseen by consultant anaesthetist, Dr Noel Gavin.

Dr Gavin had stated on the second day of the inquest, that the double lumen tube, needed to ventilate the patient, had been fitted correctly.

He stated that he could clearly recall seeing the vocal chords as the tube passed down.

However, there was no capnography trace (relating to carbon dioxide levels) recorded on the monitor which, according to independent expert witness Professor Jonathan Hardman, was indicative of an incorrectly placed lumen tube.

Professor Hardman had also stated Mr Hargreaves’ abdomen was found to have become distended during intubation, with the only explanation being that the tube had been wrongly placed in the oesophagus.

The court had also heard from Dr Manoj Purohit - consultant cardiothoracic surgeon at Blackpool Victoria Hospital, who had carried out the initial removal of the lung.

Dr Purohit, in his statement, had disagreed with Dr Gavin’s account that the cardiac arrest had occurred before intubation, believing it had occurred afterwards.

Narrative verdict

Recording the narrative verdict, Ms Rae concluded that the medical cause of Mr Hargreaves’ death was acute cardiac failure, as well as the hypoxic brain injury, along with pre-existing coronary artery atherosclerosis, myxoid degeneration of the mitral valve, as well as hypertensive heart disease.

Post operative bleeding after the right pneumonectomy for carcinoma was also included.

Ms Rae also stated: “Oesophageal intubation in itself is not a failure to provide basic medical attention.

“For the avoidance of doubt, even if I felt oesophageal intubation ought to be regraded as “basic medical attention”, failing to recognise and correct oesophageal intubation would not be categorised as a gross failing in the context of coronial neglect.”

Chris Barben, Executive Medical Director at Blackpool Teaching Hospitals, said: “We would like to offer our sincere condolences to Mr Hargreaves’ family. The Trust has been present at the inquest and understands how difficult this has been for everyone.

“We apologise for any delays in how Mr Hargreaves’ death has been investigated which we know has made this process harder.

“We have since made a number of changes to the way we work, including the introduction of an independent Medical Examiner’s Office to scrutinise circumstances like these. Our serious incident processes have also changed.

“I’d also like to offer reassurance that we have worked hard to reduce the risk of such an incident ever taking place again.”