The husband of a Pulham Market woman who died at home two days after a varicose vein operation says his life has been ‘destroyed’ and is considering legal action against Norfolk and Norwich University Hospital (NNUH).
The inquest into the death of mother-of-two Nicola Tweedy, 54, of Duxford Road, was concluded in Norwich this week.
Mrs Tweedy, a classroom assistant, had day surgery on her right leg at the hospital on March 27, 2014, and was discharged later that evening by nurses.
But two days later she was found by her adult son Alex lifeless in a chair. She had suffered a pulmonary embolism – which is usually caused by a blood clot.
The family claim the hospital did not follow National Institute for Health and Care Excellence (NICE) guidelines for patients who could be at risk of blood clotting.
In her narrative verdict, senior coroner Jacqueline Lake concluded: “Mrs Tweedy died following a rare but recognised risk of appropriate surgery,”
Speaking to the media following the inquest, Christopher Tweedy said his children’s lives had been “damaged beyond repair”.
“Pending possible civil action to be undertaken by me against the NNUH, I cannot, at this stage, list how I believe the NNUH failed my wife, failed us as a family,” he said.
“The NNUH were required, by the NHS Charter, to provide a high standard of care to my wife and, in my opinion, they did not. They were required to do all that they could to minimise the risk to her and, in my opinion, they did not.
“They were required to avoid harming her and, tragically, in my opinion, they did not. They were required by the terms of the Standard NHS Contract to comply with the relevant NICE Guidance and, in my opinion, they did not.
“The NNUH vision statement is: ‘To provide every patient with the care we want for those we love the most’. In my opinion they most definitely failed to fulfil that vision for my wife, for the person we loved the most.
“She was my everything, she was my soulmate, she always will be. I love her with all my heart and I will do always.”
He added he was “relieved” that the coroner agreed with his view that Mrs Tweedy should have been given an extended course of pharmacological prophylaxis following the operation, which he believes could have prevented her death.
A statement issued on behalf of the hospital said: “We again express our sympathy to Mr Tweedy and his family for their loss.
“Mrs Tweedy received treatment in accordance with nationally accepted practice. She died of a rare but recognised complication of surgery, estimated to occur in approximately 0.01 per cent of cases, in other words one in 10,000 patients.
“Whilst it is possible to reduce the risks of surgery they can never be eliminated entirely. The Trust commissioned an independent review in order to identify any ways in which we could improve our services.
“Once we have the Coroner’s recommendations we will review these to identify any further opportunities for improvement.”
The inquest heard how Mrs Tweedy saw Robert Brightwell, a consultant vascular surgeon at the NNUH for treatment for her varicose veins.
But when Mr Tweedy came to the hospital following the operation to pick up his wife, he said her eyes “were like pin pricks” and she “was not really with it” but was allowed to be discharged.
He said he had not received a leaflet on the risks of deep vein thrombosis, which they should have done.
Mr Tweedy told the inquest: “I still had concerns at that point. I did not voice them and I will always regret that.”
Mr Brightwell told the inquest he could not recall if he had discussed the potential risks her obesity could have had on the operation. He said if he thought her weight was a big concern, he would have deferred the surgery.
He said there were no complications during the operation.
He also conceded that a thrombosis risk assessment, which should have been completed on the morning of the procedure, was not completed. It was subsequently learned this was never filled in.
Mr Brightwell said if the form was completed before or after the surgery, it would have made no difference in the measures taken post operation.
Nurse Susan Browne conceded it was “an oversight” on her part that the discharge checklist was not filled in on the evening of Mrs Tweedy’s discharge from the hospital.
A statement from South Norfolk MP Richard Bacon read: “Mrs Tweedy’s case is a tragedy for her family and all who knew her. The Coroner stated she will be making a report that future deaths can be prevented following a number of issues raised during the inquest. I welcome this.
“The agreed facts in Mrs Tweedy’s case are that a risk assessment that should have been carried out was not done; that Mrs Tweedy was not given relevant information leaflets; that a discharge form was not completed for Mrs Tweedy when she left the hospital; and that she was not warned that a high body mass index was an extra risk factor for the operation. Numerous aspects of the hospital’s procedures have now changed, as a consequence of this case.
“It is clear to me that more could and should have been done to mitigate the risks of what was deemed to be appropriate surgery for Mrs Tweedy, most crucially to place Mrs Tweedy and her family in a position to make a fully informed choice about whether to proceed with the operation.
“We need an intelligent and open discussion about these issues. The Norfolk and Norfolk Hospital does a truly excellent job for thousands of patients every week and people in Norfolk hugely value its role and the hard work and commitment of its staff.
“It is not about blaming people but about making sure – instead of just reciting the mantra – that lessons actually are learned.”