A coroner has heard that there was a missed opportunity to save the life of a patient who died at the Cumberland Infirmary.
44-year-old Sharon Grierson died from a lack of oxygen after a breathing tube was accidentally put into her oesophagus instead of her wind pipe.
She had been undergoing a procedure to remove a polyp from her vocal cord in November 2016.
Doctors failed to notice their mistake and she went into cardiac arrest. She died in hospital three days later.
Giving evidence at Cockermouth Coroner’s Court today, Monday 22 January, expert witness Doctor Bernard Norman said doctors were well aware that Mrs Grierson was not breathing properly because a monitor was showing she wasn't producing carbon dioxide.
But he said the cause of her breathing problems was “misinterpreted” by the anaesthetists who were present.
He said the anaesthetist in charge, Dr Jenny Fraser, believed she had seen Mrs Grierson’s breathing tube in the correct place so was looking for another cause of the problem.
It was only afterwards that the real reason became apparent.
However Dr Norman said he didn’t believe there was a basic lack of care or neglect on behalf of hospital staff. During the incident, anaesthetists had twice tried to insert a tube into Mrs Grierson.
The first tube was discovered to have been wrongly put in her oesophagus and was removed. But the second tube was also incorrectly inserted.
Appearing on behalf of North Cumbria University Hospital NHS Trust, Doctor Nicholas Strong said sorry to the family for Mrs Grierson’s death and said an action plan had been put in place to help prevent similar incidents in future.
The inquest is expected to conclude tomorrow.