NEED TO KNOW
Jean Dye, 77, went into surgery for a stent in order to treat an underlying heart condition
During a critical moment in the surgery, the operating room lost power for 10 minutes, leading to her death
A coroner said in a report that Dye “would have survived” if the operating room didn’t lose power and suggested action be taken to prevent future deaths
A woman died during heart surgery after the hospital’s operating room had a power outage for ten minutes, a coroner concluded at an inquest into her death.
On Wednesday, August 13, a Prevention of Future Deaths report was released following a five-year investigation of the death of Jean Dye.
In September 2020, Dye, 77, visited Scunthorpe General Hospital in England to be treated for an underlying cardiac disease. She was undergoing a percutaneous coronary intervention, also known as angioplasty with stenting. According to the Cleveland Clinic, it’s a minimally invasive surgery to open a blocked artery in the heart using a small, permanent tube called a stent.
Senior coroner Paul Smith explained that during the surgery, doctors only have a limited window to deploy the stents. However, during that window, the operating room experienced a “sudden and unexpected failure of electrical power” that lasted for 10 minutes.
“The loss of electrical power removed the ability to provide X-ray images and consequently prevented commencement of the stenting procedure until power was regained,” he said in the report.
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Stock image of woman in a hospital
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Smith said there was no clear cause of the power loss and that there was no manual activation of circuit. Staff, who reportedly had never been in a situation like that before, were then forced to wait for an engineer to come and restore the power.
Once the power was restored, doctors were able to complete the stent. However, Dye “failed to recover” and she died. Her cause of death was confirmed as an iatrogenic artery dissection during a percutaneous coronary intervention.
“On balance of probabilities, Mrs. Dye would have survived but for the loss of electrical power,” the report states.
Smith has since sent the report to NHS England and the Health Service Executive, giving them until August 28 to respond. He suggests action be taken to prevent future deaths. His list of concerns include the fact that the reset button was located elsewhere in the hospital and there was no light or indicator in the operating room to confirm that the circuit had activated.
“In my opinion there is a risk that future deaths could occur unless action is taken,” he said.
“Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who in turn had to attend a separate plant room, the downtime would likely have been significantly reduced,” Smith continued. “Whilst it was not possible to say that the additional time spent on this occasion made a difference between the patient surviving or not, there may well be future cases within which such fine margins are time critical.”
Read the original article on People
