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Malcolm Green died after cancer operation, inquest hears 'Care failings' over Malcolm Green's death after cancer op
(about 2 hours later)
A Pembrokeshire businessman died after "failings in the level of care" he was given following routine surgery for cancer, his inquest has heard. A businessman died after failures in the care he was given following routine surgery for cancer, his inquest has heard.
Malcolm Green, 82, died in June 2012 after an operation to remove a tumour at Withybush Hospital, Haverfordwest. Malcolm Green, 82, died in June 2012 after surgery at Withybush Hospital, Haverfordwest, to remove a tumour.
He suffered internal bleeding which was not immediately noticed by staff, heard the hearing in Milford Haven. In the hours after the operation, he suffered internal bleeding which was not immediately noticed by staff, the hearing in Milford Haven was told.
Hywel Dda University Health Board admitted it failed to respond to his condition. The health board admitted it failed to respond to his condition in time.
The inquest on Tuesday heard from nurses and a senior doctor who were monitoring Mr Green's blood pressure following the elective laparoscopic right hemicolectomy on 25 June 2012. The inquest on Tuesday heard from staff nurse Stephanie Reynolds who cared for Mr Green on the evening of 27 June 2012.
At 04:30 BST his blood pressure fell and by 06:30 it had fallen considerably more. Ms Reynolds said she and another nurse, plus two healthcare assistants, were looking after a total of 30 patients that evening.
The nurse said there were no particular issues of concern about Mr Green who had undergone open surgery to remove a tumour on his colon earlier.
She told the inquest that Mr Green's blood pressure fell but she "didn't think it was that low".
While she was on a break, his blood pressure dropped again at 04:30 and by 06:30 it had fallen again.
Internal bleedInternal bleed
Dr Ian Lane told the inquest Mr Green's condition was not flagged up to a registrar because he seemed to be responding to fluids administered and was alert and chatty. The doctor on duty, Ian Lane, said the night in question had been busy with greater pressure than usual.
The internal bleed was eventually identified and Mr Green was prepped for emergency surgery at 10:00 BST. He told the inquest he had had concerns about a possible cardiac problem due to Mr Green's medical history and that internal bleeding was also a concern.
But the operation did not take place until at least three hours later and Mr Green died three days later. But despite the drop in Mr Green's blood pressure, he did not alert a senior doctor because the patient appeared to be responding to fluids and was "very alert and chatty".
At 07:00, when Dr Lane finished his shift, Mr Green was stable.
Staff eventually identified Mr Green was suffering from an internal bleed and he was prepped for emergency surgery at 10:00.
But the operation did not take place until at least three hours later.
Mr Green, who was made an MBE for his services to the community in the New Year's Honours in 2011 and was well known as the owner of car dealerships in Pembrokeshire, died three days later.
He had been an active member of Haverfordwest Rotary and the Museum Trust in Pembrokeshire.
In a statement released to the BBC the health board admitted failures in Mr Green's care.
Dr Sue Fish, medical director at Hywel Dda University Health Board Trust, said: "The university health board sincerely apologies to the family of Mr Green and offer our deepest sympathies to them.Dr Sue Fish, medical director at Hywel Dda University Health Board Trust, said: "The university health board sincerely apologies to the family of Mr Green and offer our deepest sympathies to them.
"We acknowledge there were failings in the level of care Mr Green received and the university health board has carried out a full internal investigation. Actions have been taken to ensure that these failings do not happen again and these lessons will be shared widely across the university health board." "We acknowledge there were failings in the level of care Mr Green received and the university health board has carried out a full internal investigation.
Mr Green was made an MBE for his services to the community in the New Year's Honours in 2011. "Actions have been taken to ensure that these failings do not happen again and these lessons will be shared widely across the university health board."
He was an active member of Haverfordwest Rotary and the Museum Trust in Pembrokeshire.
The inquest continues.The inquest continues.