The death of a woman following breast surgery in Edinburgh's Western General Hospital was "entirely preventable".
Marlene Wightman, from Dalkeith, bled to death after a mastectomy operation in March 2006. Now, procedures in Ward 6 of the hospital have been heavily criticised by a Sheriff following a Fatal Accident Inquiry in the capital.
In a written determination released on Friday, Sheriff Isabella McColl said a number of reasonable precautions might have prevented Mrs Wightman's death.
They included earlier diagnosis that she was haemorrhaging, transferring her to a high dependency unit for at least 24 hours after her surgery and providing adequate training and guidance to nursing and junior out of hours medical staff.
Sheriff McColl also suggested there were serious defects in the hospital's procedures which contributed to Mrs Wightman's death. As well as the lack of adequate training, she cited a failure to provide adequate induction, education and out-or-hours cover for inexperienced staff and a failure to establish correct handover procedures between the breast surgery and ward staff.
Medical records being kept about Mrs Wightman also came under fire as: "incomplete and contained inconsistencies, inaccuracies, alterations and errors". Ward 6, she added, lacked adequate practical oversight and management.
The determination of the case also detailed the "fairly appalling treatment" Mrs Wightman's family had been subjected to by the hospital.
Her husband, Tom, received a late night telephone call, telling him to come to the hospital immediately but not explaining why.
When he arrived, he was left in a room in Ward 6 where he was joined by the couple's son and daughter. The family could see people working on Mrs Wightman before being told she had died. An hour and half later, the on-call surgeon said he was sorry and expressed sympathy but offered no further information.
When Mr Wightman called the hospital later that morning, his motives for wanting to attend. When the family were able to return to the hospital at 10am, they were put in the room where they had witnessed the efforts to save Mrs Wightman's life.
While they were there, Mr Michael Dixon, the surgeon who had carried out the mastectomy came to see them. He was extremely upset and told the family he could see how someone could bleed to death outside a hospital, but not inside.
He said the operation was fine, but the aftercare was at fault and he advised the family to employ a lawyer. Later requests for information and records were met with reluctance by the hospital.
"The hospital has no doubt been acting on legal advice " said the Sheriff "but there must be a better way to treat people who have been so suddenly and shockingly bereaved".
An expert witness for the Crown also told the FAI that Mrs Wightman would have had an 85% chance of surviving at least ten years if she had survived her surgery.
The family's solicitor said: "The family would welcome an unreserved acceptance of the recommendations of the Inquiry and the assurance that all parts will be fully implemented immediately."
In a statement, husband, Tom, son, John and daughter, Lisa, described their wife and mother as "The heart and soul of our family".
"We have lived our lives for nearly four years since Marlene passed away, hoping that one day we would wake from what is the worst possible nightmare. Not a day goes by without us remembering her."
Their statement added: "It pains us deeply to have heard during a very lengthy Fatal Accident Inquiry over the course of a year that Marlene was suffering for hours before anyone realised she was deteriorating.
"When her deterioration was finally recognised it was too late to save her. Marlene fought for a long time to stay alive, but was failed by the system that so many of us put our trust in".
Last updated: 06 November 2009, 19:11
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