Julie Ann Robertson · Prevention of Future Deaths report

On 30th June 2014 I commenced an investigation into the death of Julie Ann Robertson, Date of Birth 2nd October 1963. The investigation concluded at the end of the inquest on 2nd July 2014. The conclusion of the inquest was:-

Narrative Verdict

On 8th May 2013 Julie Ann Robertson had an operation for an elective total abdominal hysterectomy and bilateral salpingo Oophorectomy. The operation was uncomplicated and in recovery she was fine. She was transferred back to the ward. At around 2.00 am on 9 May 2013 her blood pressure was low and her pulse rate was up. This is a known indicator for internal bleeding. A doctor was not contacted until 3.00 am and an SHO attended at 3.10 am followed by the Registrar at 3.40 am. Although there was difficulty in obtaining a blood sample the result of a bedside haemacue test was available by 4.40 am and this showed the haemoglobin level was 8. This case was not immediately escalated to a more senior doctor. A full blood test was not available until 5.45 am and only then was a consultant contacted and for the first time there was some recognition that this was an emergency. By the time Mrs Robertson was seen by a senior
anaesthetist at 6.17 am she was unfit for immediate surgery. This was mainly due to blood for a transfusion still being unavailable despite the fact that the possible need for such blood had been recognised by 4.40 am. The blood eventually arrived at the ward by 6.55 am when the delayed blood transfusion was finally started. Despite the fact that 2 surgeons were in theatre ready to operate by 7.19 am the operation could not commence until around 8.00 am because Mrs Robertson was too unwell to be given a General Anaesthetic. When they were able to operate the surgeons did their best but it was too late. Mrs Robertson's chances of a successful recovery had been reduced by the earlier delays. Record keeping throughout was poor and timings were unclear. Julie Ann Robertson died on 11th May 2013 as a result of complications following the operation as set out above.

See Narrative conclusion above.

1) The possible need for blood had been anticipated as early as 4:40am. If there had been a blood fridge on the ward then the matched blood could have been brought to the ward so that when a transfusion was called for it would have been instantly available on the ward. The blood eventually arrived at 6.55am by which time Mrs Robertson was unfit for surgery.

2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping.