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| Coroner criticises care of woman who died after kidney stone operation | Coroner criticises care of woman who died after kidney stone operation |
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| A series of medical “absences” played a part in the death of a woman 14 years ago after a routine kidney stone operation, the third inquest into her death has ruled. | A series of medical “absences” played a part in the death of a woman 14 years ago after a routine kidney stone operation, the third inquest into her death has ruled. |
| Carmel Bloom, 54, from Ilford, Essex, died on 8 September 2002, after surgery at the private Roding hospital in Ilford, where she worked as a health controller. She was taken to Whipps Cross intensive therapy unit (ITU) but died after her blood pressure fell and she suffered cardiac arrest. | Carmel Bloom, 54, from Ilford, Essex, died on 8 September 2002, after surgery at the private Roding hospital in Ilford, where she worked as a health controller. She was taken to Whipps Cross intensive therapy unit (ITU) but died after her blood pressure fell and she suffered cardiac arrest. |
| This new inquest was ordered in 2014 at the request of her family, who said fresh evidence had come to light. | This new inquest was ordered in 2014 at the request of her family, who said fresh evidence had come to light. |
| The coroner, Karon Monaghan QC, of West London coroner’s court sitting at the Royal Courts of Justice, dismissed arguments for ruling her death an unlawful killing. | The coroner, Karon Monaghan QC, of West London coroner’s court sitting at the Royal Courts of Justice, dismissed arguments for ruling her death an unlawful killing. |
| She said: “Carmel Bloom’s death was contributed to by the absence of regular monitoring, the absence of timely communication between nursing staff and the consultant urological surgeon, the absence of timely communication between the consultant urological surgeon and consultant anaesthetist, and the absence of intubation and ventilation prior to transfer from Bupa Roding hospital to Whipps Cross ITU.” | She said: “Carmel Bloom’s death was contributed to by the absence of regular monitoring, the absence of timely communication between nursing staff and the consultant urological surgeon, the absence of timely communication between the consultant urological surgeon and consultant anaesthetist, and the absence of intubation and ventilation prior to transfer from Bupa Roding hospital to Whipps Cross ITU.” |
| Bloom had the procedure late on 28 August. She was returned to the ward but her blood pressure began to fall early on the next day. The consultant urological surgeon telephoned staff and gave instructions about her ongoing care – including half-hourly observations – but her condition deteriorated and her “vital signs were not consistently recorded”, the coroner said. | Bloom had the procedure late on 28 August. She was returned to the ward but her blood pressure began to fall early on the next day. The consultant urological surgeon telephoned staff and gave instructions about her ongoing care – including half-hourly observations – but her condition deteriorated and her “vital signs were not consistently recorded”, the coroner said. |
| Bloom’s blood pressure continued to fall and by 2am she was septic, the coroner said. The consultant urological surgeon was not called until 2.55am and arrived 20 minutes later. | Bloom’s blood pressure continued to fall and by 2am she was septic, the coroner said. The consultant urological surgeon was not called until 2.55am and arrived 20 minutes later. |
| The consultant anaesthetist was not called until 4.29am, “by which time” Bloom was suffering from pulmonary oedema, the coroner said. She was rushed to Whipps Cross ITU. | The consultant anaesthetist was not called until 4.29am, “by which time” Bloom was suffering from pulmonary oedema, the coroner said. She was rushed to Whipps Cross ITU. |
| The coroner said: “The consultant anaesthetist did not intubate and ventilate Carmel Bloom before transferring her, or attach equipment which would have allowed for the monitoring of her vital signs during transfer. Shortly after arrival at ITU Carmel Bloom went into cardiac arrest. She experienced severe hypoxic brain injury and did not regain consciousness.” | The coroner said: “The consultant anaesthetist did not intubate and ventilate Carmel Bloom before transferring her, or attach equipment which would have allowed for the monitoring of her vital signs during transfer. Shortly after arrival at ITU Carmel Bloom went into cardiac arrest. She experienced severe hypoxic brain injury and did not regain consciousness.” |
| She remained on life support until 8 September when the decision was taken to turn the machine off. | She remained on life support until 8 September when the decision was taken to turn the machine off. |
| The first inquest in 2003 found that Bloom died of natural causes, but that verdict was quashed by the high court in December 2004. The second inquest in 2005 at West London coroner’s court found that a lack of post-operative care contributed to her death. That finding, deemed inadequate by the Bloom family, was also quashed. | The first inquest in 2003 found that Bloom died of natural causes, but that verdict was quashed by the high court in December 2004. The second inquest in 2005 at West London coroner’s court found that a lack of post-operative care contributed to her death. That finding, deemed inadequate by the Bloom family, was also quashed. |
| The family said fresh evidence, including an expert report and a 999 call in which the night sister at Roding is describing the seriousness of Carmel’s condition to emergency services, should at last give a full picture of how she came to die. | The family said fresh evidence, including an expert report and a 999 call in which the night sister at Roding is describing the seriousness of Carmel’s condition to emergency services, should at last give a full picture of how she came to die. |
| After delivering the ruling, the coroner turned to Bloom’s brother Bernard, and passed on her condolences. “I hope that this inquest has given you the opportunity for some of your questions to be answered,” she said. | After delivering the ruling, the coroner turned to Bloom’s brother Bernard, and passed on her condolences. “I hope that this inquest has given you the opportunity for some of your questions to be answered,” she said. |
| After the hearing, Bernard Bloom said: “Carmel was let down and the system has badly let down the family … This has taken over 14 years. I could not have done this any quicker. It was bad enough what happened to Carmel, but what happened to the family, it is a disgrace. It is the system that needs to be amended.” | After the hearing, Bernard Bloom said: “Carmel was let down and the system has badly let down the family … This has taken over 14 years. I could not have done this any quicker. It was bad enough what happened to Carmel, but what happened to the family, it is a disgrace. It is the system that needs to be amended.” |
| A spokeswoman for Bupa, which owned Roding hospital in 2002, said: “We sympathise with Carmel Bloom’s family for their loss. Her colleagues at the hospital were all deeply affected by this tragic incident in 2002. | |
| “As we no longer own the hospital, it’s not appropriate for us to comment any further.” |