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Doctor’s U-turn shocks inquest
Family misled by report’s initial findings
A CORONER has called for better communication between doctors and pathologists after the family of an elderly man were wrongly led to believe that a botched heart bypass caused his death.
Dr Shirley Radcliffe made the remark after a pathologist made a dramatic u-turn in his findings at Westminster Coroner’s Court on Wednesday.
Pathologist Dr Michael Osborn back-tracked on his own report into the cause of death after hearing evidence from a heart surgeon who performed the difficult double bypass on Nanayakara Gunawardena.
The inquest heard that the haemorrhaging which led Mr Gunawardena, 76, to suffer a cardiac arrest at St Mary’s Hospital on December 3 last year was not caused by a tear in the heart wall sustained during the operation.
Had Dr Osborn read the patient’s medical notes and consulted cardiothoracic consultants he may have come to this conclusion in the first place, the coroner said.
Dr Radcliffe said: “The minute details of how a heart would look following this kind of operation were not clear to Dr Osborn when he made his report. This is not a personal criticism.
“On hearing two surgeons’ evidence, it is clear that there was no catastrophic bleeding from the aorta.
“A full and frank discussion between both parties should have taken place.
“After a major reconsideration of all the evidence, nothing suggests a major interior bleed.”
Mr Gunawardena, from Willesden, died from cardiac arrest in the Paddington hospital less than a week after an operation to his already “severely diseased” heart.
Following what Dr Radcliffe called a “fruitful investigation”, in which the court were led through the complex procedures of aortic valve replacement and bypass surgery in anatomical detail, the coroner concluded that death could not primarily be attributed to a tear.
Blood loss suffered by Mr Gunwardena was “consistent” with his condition and the emergency procedure initiated to try and revive him, the inquest heard.
Dr Radliffe recorded death caused by complications of necessary surgery. |
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