Hospital slammed over woman's death

A hospital was today criticised over "systematic failings" in the care of a woman who died after an operation.

• Ninewells Hospital

NHS Tayside has apologised to the family of the 28-year-old, who had learning difficulties and died the day after surgery on her parotid gland, a saliva-producing organ near the ear.

A report by Scottish Public Services Ombudsman Jim Martin set out a series of shortcomings in the woman's care, both before and after the operation, at Ninewells Hospital in Dundee two years ago.

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It concludes: "I have found systematic failings in the post-operative care of Miss C, specifically in relation to the lack of recording of blood pressure and other vital signs, communications, record-keeping and decision-making.

"I conclude that failings on the part of the consultant anaesthetist, the consultant surgeon and the nursing staff all contributed to this."

The woman, identified only as Miss C, suffered from myotonic dystrophy, which causes muscle weakness, and dystrophia myotonica was found to be the primary cause of death.

But a post-mortem report found that surgery and the post-operative period can place stress on the heart muscle and, in this case, may have left Miss C susceptible to abnormal heart activity.

The report found "process failures" prior to surgery, which mean the woman was not properly assessed at a formal pre-operative clinic.

Miss C came out of surgery at 8pm on March 31 2008, but the report found her blood pressure and other vital signs were not recorded after 9.15pm that night.

She was found to be unresponsive at about 10.30am the following day and declared dead shortly afterwards.

The report says that she should have had a heart monitor during her post-operative care and that there was a "breakdown in communication" between the consultant surgeon and nursing team.

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Communications with the family were also not appropriate, according to the report.

NHS Tayside is now to review its arrangements for pre-operative care and post-operative treatment for people with learning disabilities to avoid a repeat.

A spokeswoman for NHS Tayside said: "We accept all of the Ombudsman's recommendations and will be writing to the family offering a full apology."

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