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'Care failings' over Malcolm Green's death after cancer op Malcolm Green: Organ failure after cancer op bleed
(about 4 hours later)
A businessman died after failures in the care he was given following routine surgery for cancer, his inquest has heard. A businessman had little chance of surviving complications following a cancer operation, an inquest has been told.
Malcolm Green, 82, died in June 2012 after surgery at Withybush Hospital, Haverfordwest, to remove a tumour. Malcolm Green, 82, began bleeding internally after surgery to remove a tumour at Withybush Hospital, Haverfordwest, in 2012.
In the hours after the operation, he suffered internal bleeding which was not immediately noticed by staff, the hearing in Milford Haven was told. The Milford Haven hearing was told Mr Green died three days after emergency surgery to treat the bleeding.
The health board admitted it failed to respond to his condition in time. Officials have admitted failing to respond to his condition in time.
The inquest on Tuesday heard from staff nurse Stephanie Reynolds who cared for Mr Green on the evening of 27 June 2012. On the first day of the inquest, the hearing was told that Mr Green had undergone surgery on 27 June to remove a tumour in his colon.
Ms Reynolds said she and another nurse, plus two healthcare assistants, were looking after a total of 30 patients that evening. But alarms bells began to sound overnight, as his blood pressure began to drop.
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. The following morning, staff indentified the internal bleeding and he was prepared for emergency surgery at 10:00 BST.
She told the inquest that Mr Green's blood pressure fell but she "didn't think it was that low". However, that procedure did not get underway for another three hours.
While she was on a break, his blood pressure dropped again at 04:30 and by 06:30 it had fallen again. Organ failure
Internal bleed Surgeon Otumeluke Umughele told the inquest that it was clear there had been post-operative bleeding, possibly as a result of a stitch that had slipped.
The doctor on duty, Ian Lane, said the night in question had been busy with greater pressure than usual. Mr Umughele said by this point Mr Green was suffering from organ failure and his prospects of survival were very low.
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. However, the consultant rejected claims made in a statement by the hospital's lead anaesthetist Dr Joel Green, that the anaesthetist team were ready to start at 10:00.
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". In a written statement, Dr Green said he went down to a cancer clinic at 12:00 to request Mr Umughele's presence in theatre and to emphasise how sick Mr Green was, as there was still no sign of Mr Umughele.
At 07:00, when Dr Lane finished his shift, Mr Green was stable. Mr Umughele dismissed this, saying he immediately returned to theatre when Dr Green came to inform him that blood products ordered for the operation had arrived.
Staff eventually identified Mr Green was suffering from an internal bleed and he was prepped for emergency surgery at 10:00. Despite surgery finally going ahead, the businessman's condition continued to deteriorate and he died three days later.
But the operation did not take place until at least three hours later. Apology
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. Known for his car dealerships, Mr Green was made an MBE for his services to the community in the New Year's Honours in 2011.
He had been an active member of Haverfordwest Rotary and the Museum Trust in Pembrokeshire. He had also been an active member of Haverfordwest Rotary and the Museum Trust in county.
In a statement released to the BBC the health board admitted failures in Mr Green's care.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."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.""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."
The inquest continues. The inquest was adjourned to continue on Wednesday.