David Glyn Price · Prevention of Future Deaths report

On 8TH January 2015 I commenced an investigation into the death of David Glyn Price dob 2nd October 1959. The investigation concluded on the 1st June 2015 and the conclusion was one of Accidental Death. The medical cause of death was 1a Previous myocardial infarction, treated by coronary artery bypass graft and mitral valve disease treated by valve replacement 11. Steato-hepatitis; peri-cardial abscess

In early June 2011 he suffered a heart attack and was operated on at Wythenshawe Hospital. In the course of the operative procedures, a swab was inadvertently left inside his body attached to his heart. This gradually formed an abscess.

1.Before he was admitted to hospital his G.P. was prescribing warfarin and this continued over many months despite the fact that he failed on three occasions to attend the anti- coagulation clinic. There is apparently no system to prevent this happening. I have noted in many inquests that people who have “repeat prescriptions” continue to get all the drugs prescribed even if they are no longer needed or wanted, thus potentially placing the patient at considerable health risk but also costing the NHS a vast amount of money for unwanted and unused drugs.(For the Secretary of State)

2. The quality of the handwritten notes (both medical and nursing) was nothing short of very poor. They were frequently undated, unsigned and there was no indication in block letters as to who was completing the notes, his/her professional status etc.(For UHSM)

3. Even though a “specialist radiologist” looked at the X-Rays, and noted that they appeared to show a foreign body within the thorax of the patient, this was not read or seen by any of the treating doctors, or if it was seen it was not in any way acted upon. (This was of course an image of the rogue swab which was left in the body.) (UHSM)

4. There did not seem to be in place any, or any satisfactory, swab count policy, such that none of the nurses during any of the three heart procedures, noticed that there was a discrepancy.(UHSM)