A PATIENT died after a surgical error during an emergency procedure led to liver damage, an inquest has heard.

Patricia Anne Lane, 79, of Wellington, Herefordshire, was taken to Hereford County Hospital by ambulance on May 16 last year after a fall.

Despite being given oxygen by medics, she was having trouble breathing, and the decision to insert a chest drain was made by A&E staff after a scan showed broken ribs and a pneumothorax (air outside of the lung).

But Mrs Lane later died in the intensive care unit on June 1 after the drain was misplaced, causing a 9cm tear to her liver.

Dr Cesar Tomamao said the drain had appeared to be working as expected, and a chest X-ray was taken to confirm its position.

Mrs Lane’s care was later handed over to locum doctor, Ike Njere, who was unable to find the drain on the X-ray. A further X-ray revealed it appeared to be in the abdomen.

Dr Njere said he called surgical consultant Mr John Christo at 1am to discuss replacing the drain.

Mr Christo said he had understood from the call that Dr Njere had already replaced it, and that he would not have told him to do this without going to the hospital and personally reviewing the patient and X-ray.

But a further X-ray revealed the new drain was also incorrectly placed beneath the diaphragm, and Dr Njere removed this too.

Later radiology reports revealed that the pneumothorax seen on Mrs Lane’s first X-ray was no longer visible on X-ray after the first drain was inserted.

They were unable to say which drain had caused damage to the liver.

Herefordshire coroner Mark Bricknell concluded that Mrs Lane had died from bronchopneumonia, haemorrhage, sepsis and a liver injury after a drain was incorrectly inserted and recorded a narrative verdict.

A Wye Valley NHS Trust spokesperson said: “The trust has offered its sincere apologies to the family of Mrs Lane.

“The trust appreciates the coroner’s comments with regard to the early and frank admission to the family of the error and is committed to taking on board learning that it should have been quicker to respond to the family’s requests for information following the incident.”

The hospital has officially classed what happened as a “serious incident”.