Thetford grandfather died after surgery was cancelled because other patients needed procedure, inquest hears
PUBLISHED: 12:21 03 October 2017 | UPDATED: 17:48 03 October 2017
An “independent and active” grandfather from Thetford died after his emergency operation was cancelled because two other patients needed the procedure, an inquest heard.
Salesman John Brackenbury, 70, started to suffer from “crushing” headaches after having a shingles vaccination jab.
He was scheduled for emergency surgery at Addenbrooke’s Hospital in Cambridge, but another patient was prioritised ahead of him as doctors were not aware he had collapsed following a haemorrhage days earlier.
Mr Brackenbury died that night.
Dr Yogish Joshi, consultant neuro-radiologist at Addenbrooke’s, told an inquest at Norfolk Coroner’s Court in King’s Lynn that it is likely Mr Brackenbury would have survived if he’d had the operation.
Mr Brackenbury started having headaches on November 7 2016 and died at Addenbrooke’s on December 2 2016.
The grandfather, of Lodge Road, visited his GP surgery in nearby Feltwell several times as his headaches worsened over two weeks.
His family dialled 999 and he was taken to Queen Elizabeth Hospital in King’s Lynn on November 18 where he was diagnosed with viral meningitis.
He was discharged on November 23, but was taken to West Suffolk Hospital in Bury St Edmunds on November 29 where he collapsed after suffering a life-threatening haemorrhage.
Once stabilised he was taken to Addenbrooke’s and scheduled to have an emergency operation on December 1, but this was cancelled as two people needed to have the operation and doctors chose the other.
Dr Joshi said the highest risk of a further bleed is within 24 hours of a haemorrhage.
He said the risk “gradually diminishes after that” and if multiple patients need an operation they try to prioritise the person at greatest risk.
He said it was known that the other patient had a bleed within the previous 48 hours, but doctors mistakenly believed Mr Brackenbury’s last bleed was two or three weeks previously, so the other patient was prioritised.
The operation was to place a metal coil in the aneurysm using X-ray guidance, to fill the aneurysm space so it cannot fill with blood.
Asked about Mr Brackenbury’s likely outcome if he had the operation, Dr Joshi said: “We think his acute degeneration was because of a bleed and if he had had the procedure he would have been fairly unlikely to have that bleed and the likelihood is he would have survived.”
He said an on-call team was available and operations could have continued into the evening but it was not known how urgent Mr Brackenbury’s case was.
“We could have made arrangements to treat both (patients) going into the evening if we had that information that he had had a recent bleed,” said Dr Joshi.
Asked why the information was not available, he said: “It must have been lost in communication.”
Mr Brackenbury’s family described him as a “very independent and active 70-year-old” and said they felt “let down by the hospital and the medical profession”.
The medical cause of death was given as subarachnoid haemorrhage due to ruptured intracranial aneurysm.
The coroner has adjourned the hearing for three months.