Spelling mistake at Northwick Park Hospital leads to grandmother, 85, bleeding to death

An inquest heard Irmgard Cooper, 85, died hours after having a planned operation because no blood supplies were available in the theatre - due to a hospital mix-up and blunders by senior medical staff.

The pensioner had come through a serious but successful operation to repair a large bulge in the main artery to her heart.

When doctors started to release clamps and re-circulate blood around her body, her blood volume dropped dramatically and she needed a transfusion.

But cross-matched blood that had been prepared before her operation had been sent back to the blood bank because Mrs Cooper’s name had been spelt incorrectly on the supplies.

Mrs Cooper began to suffer massive internal bleeding and started haemorrhaging all over her body.

The inquest heard it took approximately two hours for the replacement cross match blood to arrive and that Mrs Cooper would have been able to survive the period had the anaesthetist – who was aware there was insufficient blood on standby – told the surgeon and delayed the process of releasing blood around the body.

Instead, all the blood in Mrs Cooper’s body was lost, and had to be replaced in entirety due to her critical condition.

Mrs Cooper’s devastated daughter, Lorraine Booker, said the situation was made worse when she spoke to the surgeon after the procedure who reassured her every thing had gone as planned apart from a “little problem” with her blood clotting.

She said: “I phoned home and told my father and the rest of the family that she had come through the operation, which devastates me now.

“I went to intensive care to see her, I took one look at all her readings and felt her body, which was ice cold, and I knew she was going to die. She was lying in a pool of blood which was running off the bed. The floor was drenched in blood.

“My father has suffered from nightmares over my mother’s death ever since. We just feel very let down and betrayed by the hospital for a death that should never have occurred.”

A mis-spelling of her German-born mother’s name from ‘Irmgard’ to ‘Irngard’ had been the trigger which ultimately led to her death.

A Serious Incident Investigation Report by a panel at Northwick Park Hospital found she died from serious blood clotting difficulties, cardio vascular collapse, haemorrhage, and that the delay in giving blood caused her death.

Mrs Cooper, who was married to husband Raymond for 62 years, and had two children and three grandchildren, had been admitted to the hospital on May 7 last year, for a repair of an aortic aneurysm.

The surgeon claimed he had not been made aware there was no blood available by the anaesthetist until the point when Mrs Cooper started becoming critically ill.

The medical team administered blood for two hours after it finally arrived and then made the decision to halt the operation.

She was sent to intensive care to be warmed and stabilised, with a plan to operate again the following day.

However, Mrs Cooper died at 11.54pm - 12 hours after the operation had been started.

Coroner Andrew Walker concluded that Mrs Cooper died from neglect at the inquest on Friday at North London Coroner's Court in High Barnet.

The coroner found gross failings in the failure to provide blood at a critical time when it was already previously known that blood would be required.

Her daughter said: “I feel so let down after knowing what had happened with the blood delay. I feel betrayed by the anaesthetist and I want him struck off by the General Medical Council. The duty of care to my mother was breached.”

Solicitor Renu Daly, from medical negligence specialists Hudgell Solicitors, attended the inquest with the family.

He said: “This catalogue of errors demonstrates an enormous breach of care and has had a devastating effect on her frail elderly husband, children, and grandchildren.

“The family is now receiving our support and advice as they want to be certain that this matter is publicly investigated and exposed, and that devastating errors such as these are never able to happen again.”

The chief executive of London North West Healthcare NHS Trust, Jacqueline Docherty, said: “I would like to offer my sincere condolences to the family of Irmgard Cooper and say how sorry I am for what happened.

“We accept the coroner’s verdict. Prior to the inquest, the trust undertook a full internal investigation, and has implemented systems to ensure that incidents of this nature do not occur again.”