6 days ago
Pensioner, 77, died during heart surgery when hospital suffered a ten-minute power cut during a crucial stage, inquest hears
A pensioner died during heart surgery at an NHS hospital after the operating theatre she was in suffered a ten-minute-long power cut, an inquest heard.
Jean Dye, 77, was at the crucial stage of the procedure when the electricity went down - meaning doctors had to delay the process as they couldn't see vital X rays.
Five years after her death, a coroner has now issued a report saying that the delay in restoring power was a 'critical factor in her death'.
It was found that an engineer was required to reset the system because it was in another part of the hospital.
In a Prevention of Future Deaths Report, Paul Smith, Senior Coroner for Greater Lincolnshire, has now raised concerns about the lack of power controls within the operating theatre and that medical professionals weren't trained in how to understand when electricity has been restored.
Mrs Dye, from Grimsby, Lincolnshire, suffered an underlying cardiac disease and attended Scunthorpe General Hospital to have it treated, the inquest was told.
At the time of her death in September, 2020, she was having stents implanted to treat narrowed blood vessels.
The operation only has a limited window to deploy the devices, the hearing was told.
However, at exactly this moment there was a 'sudden and unexpected' power cut, which lasted for 10 minutes.
It meant that medics could not see X-rays they needed for the procedure.
No clear cause for the power cut has been identified, other than it overrode the back-up electrical supply, Mr Smith said.
It was confirmed that power cuts have occasionally happened at hospitals across the country but the staff in Scunthorpe had not had this happen before.
There was no manual re-activation of the circuit meaning that an engineer had to come to fix the issue.
Once the power had returned, the stenting was completed but Mrs Dye failed to recover and she later passed away, the inquest heard.
The hearing concluded that 'on the balance of probabilities, Mrs Dye would have survived but for the loss of electrical power'.
It gave her cause of death as an iatrogenic artery dissection during a percutaneous coronary intervention.
Mr Smith raised concerns about the lack of an indicator within the lab to confirm that the power had re-activated.
There were also issues with the reset button being elsewhere in the hospital.
Mr Smith said: 'The delay whilst power was restored was a critical factor in this death.
'The loss of power arose as a result of the Emergency Power Off (EPO) circuit activating. It overrode the emergency power back up system.
'All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did.
'There was no light or other indicator within the lab to confirm to those present that the EPO circuit had activated. Likewise there was no restart button within the lab to permit the EPO circuit to be reset. That lay within the plant room elsewhere within the hospital.
'Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who in turn had to attend a separate plant room, the downtime would likely have been significantly reduced.
'Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.
'I received evidence that there is no current guidance in relation to the siting of such controls remote from the affected room. I invite review of that guidance and of the need for any consequential training.'
Mr Smith sent the report to NHS England and the Health Service Executive, who have until August 28 to respond.
