A mother-of-one who beat breast cancer died less than 48 hours after having reconstructive surgery at a Birmingham hospital, an inquest heard yesterday.
Deborah Yardley had undergone a mastectomy at Selly Oak Hospital in June 2003 and last August was preparing to have a bi-lateral breast reconstruction to regain her womanly figure.
But the 45 year old, from Quinton, Birmingham, stopped breathing towards the end of the six-hour operation on August 5, 2005.
She never regained consciousness and on August 7 her life-support machine was switched off, as she was brain dead.
Her husband, David, told city coroner Aidan Cotter: "The surgeon, Dr Kat, had told us Deborah had a 50:50 chance of survival.
"I called ICU every two hours to check on her. After the op I was told her blood pressure was stable and she was on stabilising drugs."
The following day Mr Yardley was called in to see his wife's doctor.
"When we got to the hospital she was not in the same condition, by this point she had very little chance of survival, as there was no sign of brain activity," he said.
Fighting back tears, he added: "A brain stem test proved to be negative and Deborah was in brain death. Deborah finally passed away on August 7 and her machine was turned off at 12.35pm"
Mr Yardley instructed Birmingham law firm Irwin Mitchell to investigate why the breast cancer diagnosis was delayed for six months, after a vital mammogram was mislaid by staff at the Queen Elizabeth Hospital.
In July 2005, University Hospital Birmingham NHS Foundation Trust, which runs both hospitals, admitted it had been mis-filed without Mrs Yardley being recalled for treatment. Yesterday the inquest heard how medical staff at Selly Oak Hospital told the family her deterioration was due to a pulmonary embolism, or blood clot.
But Dr Simon Trotter, a consultant pathologist based at Heartlands Hospital, said no such evidence was found during the post mortem.
He said: "I saw no evidence of any remaining tumour, I saw no evidence of any blood clot in the main veins supplying the heart and I saw no evidence of sluggish blood flow.
"I was unable to see any evidence of damage to the heart as a result of a heart attack, and under the microscope I couldn't see any sign of a blood clot".
He said her death was due to Sudden Adult Death Syndrome (SADS), which is thought to affect one in 100,000 people in Britain.
As well as receiving high levels of anaesthetic bupivicaine, Mrs Yardley was also given 8mg of adrenaline, in several doses, as Dr Martin King attempted to resuscitate her after she stopped breathing.
The anaesthetist admitted "with hindsight" there were problems with her post-operative care. Mrs Yardley's blood pressure had dropped from 120/55 to 30 in less than two hours.
"In retrospect it probably would have been better to give her lower doses during the procedure, because then the issue of patient toxicity would not have come up," he said.
"Maybe with hindsight I would have given her 10 to 15ml less, about 30 per cent less, than was administered during the procedure."
It is believed Mrs Yardley had suffered a larynospasm - an involuntary closure of the airway, depriving the air flow to the lungs - when Mrs Kat returned to the recovery room.
"Bagging a patient in this way was probably not the best course of action," said Dr King.
Chein Kat, the consultant surgeon who performed the operation, had left theatre to see her next patient.
"I returned about 20 minutes later and saw the patient had been transferred from the table onto a bed with Mr King bagging her using an anaesthetic mask," she said.
"The patient was cold and that her blood pressure was also very low, it had was at 30, which was a very significant drop.
"I don't want to give the impression that the situation was out of control. The anaesthetist is in control and he is the one in charge of what's going on around him."
The inquest was adjourned until later today. ..SUPL:
