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Doctors battling to save life were hampered by faulty equipment
DOCTORS battling to save the life of a Hampshire woman coughing up “catastrophic”amounts of blood during a cardiac arrest were hampered when they discovered the emergency equipment they needed to use didn’t work properly.
Bosses at Southampton General Hospital have overhauled practices surrounding vital resuscitation kit after a nurse had to run to another ward to find a functioning instrument to insert a breathing tube, when the two initially handed to doctors were found to be unusable.
An inquest into the death of Hazel Ladbrooke heard the first laryngoscope – which is used to open the airway and allow physicians to see into the throat – had no batteries and the second didn’t have the right size parts to fit together.
The family of the 57-year-old mum of one, who never regained consciousness and died 13 days later, complained to the hospital over the delays caused by the faulty equipment on the resuscitation trolley, which they feared contributed to her death.
Following the inquest, they said they remained concerned over the quality of care she received, blaming the systems in place in the hospital rather than doctors who did what they could.
They told the Daily Echo they would continue to press for answers in the hope of preventing other families from enduring the pain they have.
Southampton Coroner’s Court heard Mrs Ladbrooke, from Warren Avenue, Southampton, had been given the all-clear after five years of treatment for cancer in the back of her mouth just months before she was admitted to A&E after coughing up blood.
She was treated on a ward but three days later she again started coughing up blood, choking and suffering a cardiac arrest.
Anaesthetist Dr Andrew Baker was called and decided to insert a breathing tube, but he was hampered by the faulty equipment.
The inquest heard how batteries had been removed from the first laryngoscope while the second had a mismatching blade and handle because they had come from different suppliers – something that was meant to have stopped a year earlier.
Around two minutes passed while a nurse ran to another part of the hospital, before a tube could be inserted the hearing was told.
Dr Baker said throughout that time he was using a bag to try and get oxygen into Mrs Ladbrooke, meaning not enough oxygen was getting to her brain.
Coroner Keith Wiseman said it was impossible to tell if the delay stopped Mrs Ladbrooke being resuscitated because she was critically ill.
The inquest heard how Mrs Ladbrooke died 13 days later on June 17 last year.
A post-mortem revealed how, unbeknown to her or doctors, that cancer had returned.
She had also suffered from brain damage.
Dr Andrew Webb, the consultant surgeon who had treated Mrs Ladbrooke for cancer from 2005, said that had it been immediately clear the bleeding was caused by a returning cancer, if he had seen her he would have told her nothing further could be done.
The inquest also heard from the practice matron Karen Hill, who manages the hospital’s resuscitation service.
She said it was not clear why the laryngoscope batteries had been removed, since the equipment on the trolley was signed off as working.
She said the ill-fitting blade was “a rogue” which had got into the system and “shouldn’t have happened”.
The inquest was told how there are 144 resuscitation trolleys within the hospital which have since been fully checked and altered to show instantly if they have been tampered with.
Mr Wiseman recorded a narrative verdict in which he said delays in getting oxygen to the brain “clearly has the potential for adverse affect” but added that even temporary recovery following the catastrophic bleeding might have been impossible to achieve.
He added that “important issues” had been raised about defective hospital equipment which he said “might affect other cases”.
A hospital spokesman today said essential changes had already been made.
Dr Michael Marsh, medical director at SUHS, said: “This was a very sad case for everyone concerned and our thoughts remain with Mrs Ladbrooke’s family.
“The Trust introduced a number of improvements to the monitoring of resuscitation equipment following Mrs Ladbrooke’s death and we hope this action helps to provide some comfort to her family.
“However, following an internal investigation and the evidence provided to HM Coroner, we feel the failure of one piece of equipment did not make a difference to the outcome in this instance due to the severity of Mrs Ladbrooke’s condition and would urge her family to contact us directly if they have any outstanding concerns.”