The family of a Wellingborough teen who died hours after she underwent a routine appendix operation at Kettering Hospital say they have forgiven all those involved.
The two-day inquest into the death of Victoria Harrison, who died on August 16 last year, highlighted failures in communication and a lack of regular observations at the hospital – which says it has overhauled its observation policy for post-operative patients in the wake of Victoria’s death.
Victoria, or Tor as she was better known to friends and family, was found dead in her hospital bed the morning after she had her appendix removed by surgeons.
The hairdressing student was 17-years-old when she died.
Despite coroner Anne Pember highlighting a number of failures in hospital procedure, Victoria’s mum and step-dad Tracy and Stan Foskett’s solicitor, Rosamund Rhodes-Kemp, said: “The family forgive those involved and hope they can forgive themselves and move on.”
During her operation, an artery in her abdominal wall was nicked and this caused some bleeding. The surgeon stopped the bleed and was confident that it would not cause further problems.
However, pathologist Kevin West told the inquest at Rockingham Forest Hotel in Corby today (Tuesday) that Victoria had about 1.5 litres of fresh blood in her abdominal cavity – bleeding which had occurred after the operation around the ‘port’ which surgeons had used to carry out the keyhole surgery.
He said he could not say what had caused the further bleed or how long she had been bleeding for.
Recording a narrative verdict earlier today, coroner Anne Pember said: “During the surgical procedure the interior epigastric artery was damaged and Victoria suffered blood loss which was recognised by the surgeon and corrected.
“There was poor handover from theatre staff to the recovery nurse and in turn to the ward staff – in particular regarding the bleed which had occurred and had been rectified in surgery.
“There was a failure to carry out appropriate post-operative observations. Tor’s last written formal observation was at 8.15pm [the evening before her death].
“There was a further failure to conduct a formal observation following the introduction of intramuscular morphine.
“Had Tor’s observations been monitored at regular intervals, including pulse and blood pressure, it is possible that a deteriorating trend may have been recognised.”
Kettering Hospital says it has overhauled its post-operative procedures in the wake of Victoria’s death and that this would be her legacy.
Clare Culpin, director of nursing and quality, said: “The investigation after Victoria’s death identified a number of recommendations and led to some disciplinary action.
“As a result the hospital has committed to some significant changes to practice and patient care.
“Our work has included high profile internal campaigning and education around vital signs monitoring, around clinical handovers, and the use of early warning monitoring systems to identify a person whose condition is deteriorating.”
Victoria’s family, their solicitor and Kettering Hospital gave statements after the inquest, which are in the video, above.