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Mother bled to death as doctor refused to leave bed

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Published Date: 07 November 2009
A MOTHER of two who bled to death hours after breast surgery would have had the best chance of survival if a consultant surgeon had agreed to leave his home to attend to her, a fatal accident inquiry has concluded.
Among a litany of failures detailed in the report, consultant breast specialist Glyn Neades refused to leave his bed and direct the resuscitation of Marlene Wightman, 49, in the early hours of 23 March, 2006.

Mrs Wightman died of internal bleedi
ng after a mastectomy operation at Edinburgh's Western General Hospital.

Sheriff Isabella McColl said it should have been clear to Mr Neades that Mrs Wightman was seriously ill and it would have been "good practice" for him to attend after junior doctors called him three times.

"If he had attended he would have been best able to direct and co-ordinate the efforts of the junior medical and nursing staff to resuscitate Mrs Wightman so she would have had the best possible chance of survival," the inquiry determination said.

It went on: "It may have been the case … Mr Neades' presence would not have made any difference to Mrs Wightman's outcome, but it would have been important that a consultant did attend so that someone with a senior background and experience was present to co-ordinate and direct the resuscitation."

The failure by Mr Neades, who declined to comment yesterday, was just one of a string of mistakes in the care of Mrs Wightman the inquiry said.

Ms McColl said the patient was moved from the recovery unit too quickly and the new ward lacked "adequate practical oversight". Medical staff on site were inexperienced and Mrs Wightman, of Dalkeith, Midlothian, was given an anticoagulant drug linked to previous cases of severe post-operative bleeding.

Her medical records were found to be riddled with "inconsistencies, inaccuracies, alterations and errors". Hospital management had been aware of gaps in staff knowledge for years before the incident but had failed to address them.

Elaine Motion, the Wightman family lawyer, said the determination was "a damning criticism" of the management of medical staff in the ward.

She added: "It came out in evidence it was the blind leading the blind. That aptly describes the way the nurses and the staff dealt with the situation."

In a statement, Mrs Wightman's husband Tom, son John and daughter Lisa said the death had devastated their family.

"It pains us deeply to have heard that Marlene was suffering for hours before anyone realised she was deteriorating.

"When her deterioration was finally recognised it was too late to save her. Marlene fought for a long time to stay alive but was failed by the system."

NHS Lothian medical director Charles Swainson said the board accepted that Mrs Wightman and her family had been "severely let down".





Page 1 of 1

  • Last Updated: 07 November 2009 12:20 AM
  • Source: The Scotsman
  • Location: Edinburgh
 
1

Charles Linskaill,

Edinburgh 07/11/2009 01:05:31

This must be still a very sensitive issue for the Family and Loved ones of Mrs Wightman.
With my respect for the Family involved, I will keep comment light.

I have argued the case, that even or GP's now will not attend or have anything to do with, medical emergencies, outwith their 9pm-5pm hours of work, It never used to be like this.

My concerns were put in place, for young single
mothers, with a child, who she suspected Meningitis, and had no transport, similarities comes to mind.



2

Alice Cooper,

07/11/2009 03:32:51
a doctor should call if summond,we are all human,and life can be lost even when its not thought the patient to be in danger
the human body is still a complex thing,and it can shut down if it so wishes,as we have seen with healthy and fit footballers etc just dropping dead when they would be the last person,to be suspect of bad health
i just hope valuable lessons have been learned ,and this does not happen agaim,with a tragic and unessary loss of life
3

fife runner,

07/11/2009 07:09:50
#1 and no Saturday work now either.
4

fife runner,

07/11/2009 07:10:36
although it is too easy now to jump on bandagon and begin berating the whole profession.
5

common sense voice,

07/11/2009 08:15:54
so there was no one else there?
6

livilion,

livingston 07/11/2009 10:37:03
4 fife runner
My mother almost died in similar circumstances in Hairmyres over twenty years ago.
She now lives with Hep C and heart pills for damage caused by loss of blood, she was also transfused with US contaminated blood, and has lost her state pension.

If that was not bad enough, her GP had for decades misdiagnosed her Ceoliac disease as 'iron deficiency', this only came to light when specialists trying to save her life ran the right tests.

She made the front page of the Daily Express looking like a WWII concentration camp victim when my father was told her then undiagnosed coeliac was liver cancer and that she had a week to live.

When her medical tribunal came up this GP refused to hand over her incriminating medical notes, but when pressed ripped out the offending pages in front of her in his surgery. He then emmigrated to South Africa and retired.

He needn't have bothered because his best man chaired the tribunal and threw her case out as having nothing to answer.

Because of them my mother now in her 70s lost her state pension because she'd lost so many stamps off ill, and lives under the cloud of Hep C and liver cancer, and must forever take heart drugs for a condition her doctor denied she has.
Today she has to work as a lollypop woman because she's unable to retire.

I could go on, but if this case was a front page headline and taken up up in vain by her then Front Bench MP what chance has anyone else?

Bandwagon?
For decades the profession has closed ranks, covered up for each other, and simply buried their mistakes.
7

,

07/11/2009 10:43:24
Comment Removed By Administrator
Reason:
8

livilion,

livingston 07/11/2009 10:55:47
5 common sense voice
No
9

luby,

07/11/2009 13:02:28
Cant comment on Dr Neades however Mike Dixon was the surgeon involved in the surgery. He is a wonderful man who has saved the lives of many including myself. I thank him in my head most days for giving me to date 10 years extra life. I have been following this case and he seems to have been, as is his nature, honest and as helpful as possible to the poor family who lost their loved one. Whilst this has been a tragedy and there have been greivous errors committed, it should not be forgotten that Ward 6 and its staff have made life better for thousands of people and their families over the years and it would be wrong to vilify them.
10

Alice Cooper,

07/11/2009 13:29:24
#9 totaly agree mike dixon,now prof dixon is a highly skilled surgeon,whom i can only thank day in day out for saving my wife
he as always has shown proffesionalism,care and is always for the patient
he writes many articles,goes off round the world doing lectures etc,all fees he gets for outside work are ploughed straight back in to the breast care ward etc,to provide for patients
here is a man who thinks more of his patients than his salary
he was trained by the nhs and puts back more than he recieves
ward 6 staff and those who work with prof dixon in oncology deserve praise for the work they do
to vilify prof dixon ,as it wasnt him who refused to get out of bed is wrong
mistakes do happen,and tragic as they are ,it happens whether you are a surgeon or a car mechanic
11

drunken proffet,

Tassy 08/11/2009 08:09:33
I agree with #11. You have dedicated doctors and those involved with cosmetic surgery and boob jobs. If you had young doctors and experienced nurses attending her, I reckon she would be looking at 99% of the action.
12

Alastair 54,

South Lanarkshire 08/11/2009 17:05:57
First, let me express my sympathy to the family of Mrs Wightman. Having read the full court opinion on the Scottish courts website, it is clear this was a very tragic and needless death that could have been avoided by better post op care.
Without wishing to play down or trivialise the series of events that unfolded on that tragic day, I am struck with the similarities between the circumstances described and my own experiences within the engineering and IT disciplines. Indeed, the problem will be all too familiar to just about any service orientated organisation – how to provide adequate out of hours cover. Simply put, the issue has its roots in the specialisation of resources. Whether we are discussing the staffing of an IT department, an engineering company, a legal practice or a hospital, the concept of having individual specialisations are identical and universally recognised. Senior staff are employed as the experts in their respective fields. And simply put, the more specialised they become the more difficult it is to replicate that level of expertise elsewhere. Therefore you end up with a team of experts that are individually indispensible to the overall working of the team.
Alas, at the end of the working day when the specialists leave the building and the ‘duty watch’ take over, the organisation then has to rely on the general skills of the watch-keepers. They may well be ‘experts’ in their own right but that does not necessarily equip them to deal with situations that are effectively in someone else’s specialist area. I know myself how it felt to be confronted in such circumstances with a situation I didn’t understand. How relieved I was when I was able to call out the expert who did understand. And how frustrating it could be if the expert could not be contacted and I had to make non-reversible decisions outside my comfort zone.
In my view, the duty watch need the assurance of being sufficiently prepared and fully briefed before the departure of the d
13

Alastair 54,

South Lanarkshire 08/11/2009 17:14:48
final paragraph of comment #13 - cut off in previous post.

In my view, the duty watch need the assurance of being sufficiently prepared and fully briefed before the departure of the day workers. There should also be a clearly understood and formal escalation process where the duty staff can be augmented with on-call experts as and when required. Having been on both sides of the issue, I can understand the concerns of experts in being continually called out of hours, but that goes with the recognition and status of being ‘the expert’.
14

Ileach,

09/11/2009 23:34:59
This is truly a very complex case. However, any attending staff who has been paged/called three times by his support team should have responded. Attending physicians are only called when a concrete emergent situation exists. Any fellow (physician in specialty training) who makes up the after-hours team will take pride in doing his/her own work, and bothering the attending as rarely as possible. Any attending physician who answered, but ignored, three calls from his fellows would face severe sanctions in my hospital.

 

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