A radiographer has killed himself after a mistake during a routine procedure led to a patient’s death.
Matthew Crabtree, 31, was found dead at the Diana, Princess of Wales Hospital, in Grimsby, just days after the death of Kathleen Wise.
The retired accountant, 66, had had a heart attack after barium from an enema leaked into her bloodstream.
An inquest into Mrs Wise’s death heard how an experienced member of staff had made a fatal mistake during the test, which is used to diagnose stomach disorders.
A coroner, sitting in Cleethorpes, was told a radiographer felt responsible for the error – but that person was only referred to as Radiographer B. He is understood to be Mr Crabtree.
A note was read out to from Radiographer B, saying: ‘… my actions have led to a patient dying, due to my incompetency.’
Mrs Wise, who died three days before her 67th birthday, was said to be nervous about the procedure, which involves passing dye into the bowel to highlight any problems on an x-ray.
She was reassured by staff – but began to complain of discomfort as the process got underway. However, she was not in pain and agreed for the radiographer to continue.
Later on, Mrs Wise, of Alvingham, near Louth, Lincs, once again complained of discomfort and Radiographer B thought her bowel had gone into spasm, which was said not to be uncommon.
He then went and asked Dr Hussein Hassan, who was in a separate room, for advice. Dr Hassan did not see anything was wrong and suggested giving her a muscle relaxant. Dr Hassan told the inquest that around half an hour later, deemed to be a long time to still be undergoing such a procedure, Radiographer B again asked for his help. He said: ‘Radiographer B told me he thought he had put the tube in the wrong position. This only happens in every one in around 175,000 cases.’
Even when the liquid used in the test entered the wrong part of the body, this would not have killed her, the inquest heard. The patient then went into cardiac arrest and Dr Uthappa Belliappa came in to help resuscitate her. It took around 50 minutes to get her pulse back but she remained unconscious.
Doctors tried to save her when her heart stopped again but she later died. Pathologist Dr William Martin Peters, who carried out a post mortem, told the hearing that two tears were found and it was thought barium had entered her blood stream, resulting in a cardiac arrest.
Karen Wilson, patient services manager, who carried out an investigation into the death, told the inquest that changes have since been made: patients are made to lie in different positions, a soft catheter was now used and three persons must also be present during the procedure.
However, Coroner Paul Kelly had questioned how having a nurse or someone who was not fully qualified present would stop it from being inserted into the wrong part of the body.
Mr Kelly’s verdict was that Mrs Wise died from pulmonary barium micro-embolisation. Husband Tony Wise did not want to comment following the inquest, but his solicitor said on his behalf: ‘He is devastated at the loss of his wife and is relieved the inquest is over and accepts the coroner’s verdict.
‘He is, however, very concerned about the way in which his wife came to her tragic death and will be pursuing a civil claim.’ A spokesperson for the Diana, Princess of Wales Hospital said: “Mrs Wise came in for a routine procedure. We agree with the coroner’s conclusion and we wish to send out our condolences to the family. ‘We hope that the closing of this process can allow them to move on.’
An inquest into Matthew Crabtree’s death, which was said to be not suspicious, will be held on May 12.
No cause of death had been revealed.