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OAP died after rare condition missed

PUBLISHED: 04:16 21 February 2002 | UPDATED: 11:24 03 March 2010

A PENSIONER died in Ipswich Hospital after doctors-in-training failed to recognise a rare condition following keyhole surgery.

Florence Fisher, of Selkirk Road, Ipswich, had an operation on September 13 to unblock arteries in her leg.

A PENSIONER died in Ipswich Hospital after doctors-in-training failed to recognise a rare condition following keyhole surgery.

Florence Fisher, of Selkirk Road, Ipswich, had an operation on September 13 to unblock arteries in her leg. The procedure was a success but she suffered from internal bleeding later that night.

The next day a further operation was performed in a bid to stop the bleeding but the 81-year-old died at about 10.30pm.

An inquest at County Hall in Ipswich heard that the direct cause of her death was due to heart failure and bronchio-pneumonia, this was linked to the bleeding she was suffering from.

However the doctor who performed both operations said she would have survived had the second operation been undertaken earlier.

Dr Gary Picken, consultant radiologist at Ipswich Hospital, told the court that the initial operation to unblock Mrs Fisher's arteries had been a success.

He said: "After any event such as this I always ask myself is there anything that I could have done that I didn't do."

He continued: "I did what I had done before and have done since with very good results, this was a very unfortunate case. I did things that you would expect any radiologist to do according to techniques that are well described and well documented. This was just very sad."

The following day Dr Picken operated on Mrs Fisher after being alerted to the fact that she was bleeding. When asked by Albert Fisher, Mrs Fisher's son, if her life would have been saved if the second operation had been performed 12 hours earlier Dr Picken replied "yes".

In between the two operations staff had failed to recognise Mrs Fisher was suffering from a rare type of internal bleeding. Her blood pressure dropped and she was not passing urine. Details of her condition were not passed to the duty doctor.

Mr Fisher said: "I just feel my mother was allowed to bleed internally for possibly 17 hours without any action being taken to locate or stop it and on behalf of my family I find that unforgivable."

Alan Cameron, consultant surgeon at Ipswich Hospital, said junior staff had failed to recognise the condition Mrs Fisher was suffering from.

He added that it was a very rare condition and a recent study in Leicester revealed that only three people in 1,377 had suffered complications experienced by Mrs Fisher following the angioplasty procedure.

Ipswich coroner Peter Dean said the inquest had established the facts surrounding Mrs Fisher's death and that staff acted correctly based on their initial diagnosis and later when the true extent of her condition was realised.

He described his verdict as 'narrative' to reflect this and said there was no question over the way the care she received was provided.

He said: "Death was from complications occurring in consequence of a necessary investigative medical procedure, the exact nature of these complications initially being unrecognised."

Dr Dean said he would write to health chiefs at Ipswich Hospital to raise awareness following Mrs Fisher's death including the need for doctors-in-training to contact senior staff when faced with a diagnostic dilemma.

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