A mum who died after a planned operation was canceled three times would have survived if she had been treated earlier, a coroner has said.
Karen Dack was booked for surgery at Leicester Royal Infirmary (LRI) in April and May this year, but each procedure was canceled due to a lack of theater capacity.
Ms Dack, from Melton, Leics, ended up having emergency surgery when her condition worsened but she developed sepsis and died after the procedure, an inquest heard.
Leicester Deputy Coroner Diane Hocking said the evidence she heard showed Dack would have survived if she had undergone surgery earlier.
Dack’s partner, Emmi Akamo, said she had been failed “several times” by the hospital.
The 40-year-old told the BBC: ‘She should still be here with us. We were told it was routine, keyhole procedure and that’s why it really hurts.
“Every time she was in the hospital getting ready for surgery, doing zero-by-mouth, only for it to be cancelled.
“She was an amazing mother, full of life and love, and she just wanted to get her health right.”
Karen Dack, pictured, was booked in for surgery at Leicester Royal Infirmary (LRI) in April and May this year, but each procedure was canceled due to a lack of theater capacity
Dack’s partner, Emmi Akamo, pictured, said she had been failed “several times” by the hospital
Despite the death, a hospital chief told a coroner there were no plans for theater expansions.
In a report on the prevention of future deaths, Mrs Hocking said she feared “this problem will happen again, and further deaths may occur”.
The report, which was welcomed by the family, described how the mother-of-four suffered from symptoms of narrowing and obstruction of the bowel.
She was admitted to LRI’s emergency department in April, but urgent surgery did not occur because “there were no intensive care beds and her condition had appeared to have resolved,” the report said.
A quick operation was scheduled for May 17, but she was taken to LRI’s emergency department on May 2. Another procedure was planned but then postponed for “more urgent” cases.
The report goes on to say that a consultant had planned to operate on Dack the following day but this was not clearly communicated and she was discharged and told to return for elective surgery as previously scheduled for May 17.
But just a few days later she returned to the infirmary with abdominal pain, vomiting and diarrhoea.
Again, an operation scheduled for May 7 did not happen due to the number of operations already scheduled.
The coroner heard from a senior clinical manager at LRI who said there had been a review of how patients are prioritized for operations
The coroner went on to say that the patient’s condition continued to deteriorate on May 8, likely due to intestinal perforation, and Dack died of sepsis despite surgeons’ efforts to save her.
The coroner heard from a senior clinical manager at LRI who said there had been a review of how patients are prioritized for operations.
But he said there were no immediate plans for theater expansion at the University Hospitals of Leicester NHS Trust (UHL), which runs the LRI, and that the categorization and access to emergency theaters is “probably as good as it can get” with available resources.
Hocking’s report added: “I am concerned that although UHL is doing its utmost to address this problem, the fact is that regardless of how patients are categorized, there are still the same number of cinemas available and that this problem will happen again, and further death may occur.’
The report has been sent to the Department for Health and Social Care (DHSC) which has been asked to outline how it will address her concerns.
A further statement from Dack’s family said: “Karen was a beloved mother, daughter, sister and friend whose death was entirely preventable.
“We hope her tragic loss drives urgent reforms to ensure no other family endures such a devastating outcome.”
DHSC said it would respond to the coroner in due course and was determined to reduce waiting times for surgery.
A DHSC spokesperson added: “Our deepest sympathies are with Karen’s family and friends in this tragic case.”
Gang Xu, UHL’s deputy medical director, said: “We extend our deepest sympathies to Karen Dack’s family.
“We accept the findings of the coroner’s report and await a response from the Department of Health and Social Care.”
