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Errors during surgery revealed by whistleblower 'contributed' to woman's death.


The husband of a woman who died following complications with her hospital treatment for a digestive condition called for an investigation after an inquest into her death

Susan Warby, 57, who had been diagnosed with the digestive condition in 1997, died at West Suffolk Hospital, Bury St Edmunds, on August 30, 2018, 35 days after being admitted with abdominal pain, vomiting and diarrhea.

She went underwent emergency open surgery for a perforated bowl, which aimed to alleviate her symptoms. She died a month later following complications relating to her care.

After her death, her husband, Jon Warby, a retired police officer, received an anonymous whistleblower letter “suggesting something had gone wrong during the surgery.”

He asked for a private investigation by Suffolk police and the hospital, both of which confirmed the issues.

The inquest at Suffolk Coroners’ Court concluded that mistakes made during the first round of surgery “contributed” to her death.

A statement from her husband Jon Warby said a "rampant infection" was also putting a strain on her kidneys.

He said he was told that, during her operation, his wife had been fitted with an arterial line with an intravenous infusion to keep it clear but that his wife had been incorrectly given glucose instead of saline.

He told Suffolk's senior coroner, Nigel Parsley: "I asked what the effect of this could be and the consultant told me brain damage or death."

Mr Warby said his wife's condition was "up and down" in the following days, and she suffered a punctured lung during a further operation to replace the arterial line.

The inquest heard how Mrs Warby was rushed to hospital after collapsing at home on July 26, 2018.

The incorrect glucose intravenous fluid remained attached for 36 hours before being changed.

As a result, blood tests gave incorrect results and the wrong medication was given for two days, which led to Mrs Warby developing a brain injury of “uncertain severity.”

Senior coroner, Nigel Parsley, said the medical cause of death was multi-organ failure and recorded a narrative conclusion that the unnecessary insulin treatment “contributed” to her death along with septicaemia and pneumonia.