A GREAT-GRANDMOTHER died on the operating table after a medical blunder left the wrong size valve implanted in her heart.

Anne Bourne’s blood stopped flowing while receiving heart valve replacement surgery at Southampton General Hospital.

An inquest heard how 68-year-old Mrs Bourne, who has four grandchildren and four children, had a 29mm valve implanted during surgery.

It is a size usually reserved for large men, and was used after results from an earlier test scan were incorrectly inputted into a report by a member of staff at the hospital.

The retired care worker’s daughter, Sue Gale, questioned why the odd size was not addressed before surgery.

Consultant cardiologist John Rawlins told the inquest: “We took it that it had been measured three times.

“When it was discussed we had no way of knowing that the report was incorrect.”

A report from an investigation into the incident, which happened on June 7, revealed that the software used to measure the size of a patient’s valves made it easy for the wrong information to be transcribed due to human error.

It found the two software packages used to size valves were made by different companies and were not compatible with each other.

Coroner Grahame Short highlighted two meetings where doctors did not pick up on the error.

Mr Rawlins said that it was difficult to underestimate the impact the incident has had on the cardiac team at the hospital,

He said they have changed their working practices in light of this incident, and now perform additional checks to access the size and measurements of every patient, which are reviewed at every point of treatment, adding: “We have taken all possible steps to stop this happening in the future.”

Mr Short said: “It would be possible to describe this as an accidental death, but based on the evidence I will record a narrative verdict.

“Mrs Bourne died of the implementation of an incorrectly sized aortic valve.”

The family of Mrs Bourne, of Meadow Close, Burley, said in a statement: “We are still in shock over this whole incident and are continuing to grieve for the loss of our mother.”

In a statement issued after the inquest, Juliet Pearce, deputy director of nursing for quality at University Hospital Southampton NHS Foundation Trust, said: “Our thoughts and sympathies remain with Mrs Bourne’s family and we offer them our sincere condolences for their loss.

“We hope that throughout our contact with her family and at the inquest hearing we have reassured them we have learnt from this very sad event and have changed our practice as a result of the errors that occurred.”