Verdict expected to take an hour to deliver
The verdict at the inquest into the death of a woman who died following surgery at Noble's Hospital is due to be delivered this morning.
Coroner of Inquests John Needham has spent two days listening to evidence from staff at the hospital, as well as medical experts and the pathology report following the death of Aimee Woodward in August 2017.
The 32-year-old, who lived in Douglas, underwent surgery to treat an ovarian cyst, but suffered a cardiac arrest and hypoxic brain damage, resulting in her death nine days after the operation.
Five witnesses gave evidence in person yesterday. Josefa Ontoy and Heidi Horner, who both work as nurses on the obstetrics and gynaecology ward, gave details about the mental health nurses's condition in the early hours of the morning following her operation. They said she was stable, and was asleep when Nurse Horner went into her room at 5.30am. However, when Nurse Ontoy checked on her half an hour later she was unresponsive.
Dr Fatima Khan, who was the on-call registrar for ward four, had visited Miss Woodward shortly before midnight and had no immediate concerns over her condition. She was called back to the ward after the cardiac arrest occurred and helped with chest compressions.
Michael O'Hanlon is now the out of hours hospital co-ordinator, but in August 2017 he held the title of night manager. He revealed Miss Woodward wasn't highlighted as a patient of concern at the start of his shift, and that ward four hadn't raised any issues when he carried out his rounds. He was also involved in the resuscitation of Miss Woodward, helping restart her heart before she was transferred to ICU.
Dr Miklos Palotas was the final witness to give evidence. He was the on-call anaesthetist who was called to ward four following the cardiac arrest. While fitting Miss Woodward with a catheter he left a guidewire in her, which was discovered on an x-ray and removed three days later. Although this was described as a "never event" - something that shouldn't happen - the medical experts agreed this wouldn't have contributed to Miss Woodward's death.
Mr Needham also read details from a letter Miss Woodward's parents had delivered to Police Headquarters expressing concerns over the circumstances surrounding her death. They felt the doctors in ICU were trying to justify what had happened to the 32-year-old, but couldn't explain why she'd had a cardiac arrest.
Their letter was also critical of about the amount of time it took to check for brain activity following the cardiac arrest. They were told a specialist only comes to the Island once a month, and Miss Woodward had to wait eight days for the EEG test.
The findings of a report into the incident by the Patient Safety Quality Review Committee were also read in court. It found much of the treatment given to Miss Woodward was appropriate, but recommended some changes, including introducing a checklist to ensure guidewires aren't left in patients in future.
There were also statements from experts in anaesthesia and intensive medicine, who all agreed the hypoxia Miss Woodward suffered from during surgery and the guidewire left in after she was fitted with a catheter wouldn't have contributed to her death.
The court heard details from the post mortem report as well, which identified the most likely cause of the cardiac arrest to be related to the heart condition left bundle branch block, which Miss Woodward had previously been diagnosed with. This will all help inform Mr Needham's verdict. He told the court yesterday that this will take around an hour to deliver.