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| Kettering Hospital 'lost chances' to save blood loss girl | Kettering Hospital 'lost chances' to save blood loss girl |
| (about 3 hours later) | |
| A teenager's chances of survival after routine surgery would have significantly increased had opportunities to treat her not been lost, a coroner has said. | A teenager's chances of survival after routine surgery would have significantly increased had opportunities to treat her not been lost, a coroner has said. |
| Victoria Harrison, 17, had an appendix operation at Kettering General Hospital on 15 August last year. | Victoria Harrison, 17, had an appendix operation at Kettering General Hospital on 15 August last year. |
| She suffered blood loss and was found unresponsive the next morning. | She suffered blood loss and was found unresponsive the next morning. |
| Northants Coroner Ann Pember said it was possible a deterioration would have shown had she been regularly monitored. | Northants Coroner Ann Pember said it was possible a deterioration would have shown had she been regularly monitored. |
| Miss Harrison, a trainee beautician from Irthlingborough, Northamptonshire, had been referred to the hospital by her GP with suspected appendicitis. | Miss Harrison, a trainee beautician from Irthlingborough, Northamptonshire, had been referred to the hospital by her GP with suspected appendicitis. |
| She underwent keyhole surgery to remove her appendix on the afternoon of 15 August and during the operation an artery was damaged. | She underwent keyhole surgery to remove her appendix on the afternoon of 15 August and during the operation an artery was damaged. |
| Observation 'failures' | Observation 'failures' |
| Surgeon Shady Hosny told the inquest he rectified the bleed and that Miss Harrison had lost 200ml of blood - with 50ml being a normal loss during surgery. | Surgeon Shady Hosny told the inquest he rectified the bleed and that Miss Harrison had lost 200ml of blood - with 50ml being a normal loss during surgery. |
| The operation was a success and Miss Harrison - known as Tor - was returned to the ward, the hearing was told. | The operation was a success and Miss Harrison - known as Tor - was returned to the ward, the hearing was told. |
| She was found pale and unresponsive by a care assistant at 05:30 BST the following day, and failed to respond to CPR. | She was found pale and unresponsive by a care assistant at 05:30 BST the following day, and failed to respond to CPR. |
| The inquest heard from nurse Gillian Joy that nursing staff did not routinely read medical notes and often could not decipher a surgeon's handwriting. | The inquest heard from nurse Gillian Joy that nursing staff did not routinely read medical notes and often could not decipher a surgeon's handwriting. |
| In her narrative verdict, Ms Pember said: "There was a poor handover from theatre staff to the recovery nurse and in turn to the ward staff, in particular concerning the bleed which had occurred and been rectified in surgery. | In her narrative verdict, Ms Pember said: "There was a poor handover from theatre staff to the recovery nurse and in turn to the ward staff, in particular concerning the bleed which had occurred and been rectified in surgery. |
| "There was a failure to carry out appropriate post operative observations. Tor's last written formal observations were at 8.15pm. | "There was a failure to carry out appropriate post operative observations. Tor's last written formal observations were at 8.15pm. |
| "There was a further failure to conduct a formal observation following the introduction of morphine. | "There was a further failure to conduct a formal observation following the introduction of morphine. |
| "Had Tor's observations been monitored at regular intervals, including pulse and blood pressure, it is possible that deteriorating trend may have been recognised." | "Had Tor's observations been monitored at regular intervals, including pulse and blood pressure, it is possible that deteriorating trend may have been recognised." |
| "Windows of opportunity to treat Tor were lost - had these been acted upon the outcome may have been different. | "Windows of opportunity to treat Tor were lost - had these been acted upon the outcome may have been different. |
| "I believe her chances of survival would have significantly increased," she said. | "I believe her chances of survival would have significantly increased," she said. |
| Speaking to Miss Harrison's mother, Tracy Foskett, she added: "As a mother of two daughters, who like you are my best friends, I cannot imagine your grief and distress at the the loss of your beautiful Tor. | |
| "I am truly so sorry." | "I am truly so sorry." |
| Speaking to the BBC, Ms Foskett, said: "A mother shouldn't lose her child. I've lost my best friend. | Speaking to the BBC, Ms Foskett, said: "A mother shouldn't lose her child. I've lost my best friend. |
| "I can't ring and talk to her when I feel like it. After she died I rang her a few times, forgetting. Every morning I would wake up thinking 'it was just a dream'." |