Doctor 'devastated' by error in care of woman
BBCA doctor has told the family of a woman who died in hospital he was "devastated" by an error he made while caring for her.
Julie Penrice died at the Cumberland Infirmary in Carlisle, Cumbria, last February after she suffered a bleed to her intestine and a cardiac arrest.
A coroner heard Miss Penrice suffered a ruptured diaphragm while she was in hospital and while the initial damage was likely to have happened "spontaneously", further damage was caused while inserting a tube into her chest.
This did not cause Miss Penrice's death, the coroner said, instead she died of natural causes due to the damage caused to her body by her chronic alcohol use.
Dr Craig Oranmore-Brown was the intensive care consultant on shift at the hospital when Miss Penrice was admitted to the department.
The inquest held at Cockermouth's coroner's court heard Miss Penrice, 58, of Pearson Street in Workington, had struggled with alcohol dependency on and off for several years.
As a result, she suffered from alcohol-related liver conditions including cirrhosis, a permanent scarring of the liver.
Four rounds of CPR
Miss Penrice had been to see her GP on 8 February 2024 complaining of a swollen abdomen and was advised to go to A&E at the West Cumberland Hospital in Whitehaven.
Consultants there decided there was a risk she might have an intestinal bleed and decided to transfer her to the Cumberland Infirmary the following day, where she could have an emergency endoscopy, an examination where a camera is inserted in the body.
Before the examination could be performed on her the day after, Miss Penrice collapsed in the toilet and went into cardiac arrest.
This could have been caused by arrhythmia or a spontaneous rupture of the diaphragm, both likely in patients with liver damage.
A post-mortem revealed she suffered a ruptured diaphragm, but that could have been caused by the pressure of the CPR performed on her, the coroner heard.
Four rounds of CPR were needed to resuscitate Miss Penrice and once in the theatre, doctors bandaged a number of veins to stop some of the internal bleeding.
'Never happened before'
Miss Penrice was taken to intensive care where Dr Oranmore-Brown wanted to insert a tube into her lungs to drain fluid, to help get her oxygen levels back up.
But a scan revealed the drainage tube had accidentally been inserted into her diaphragm instead of her lung, causing a second rupture to the diaphragm.
"I am devastated by this error, which was my error. I have done hundreds of these [procedures] and it's never happened before in the way it happened in Julie's case.
"I'm glad we got a post-mortem to find out how it happened and how we can learn from it," he told the inquest.
Dr Oranmore-Brown explained his expectation was that the drainage tube would be "resting" on top of the diaphragm, a muscle which is generally quite rigid.
However, in patients with liver failure, the diaphragm becomes "almost as thin as paper".
He said: "That's why spontaneous rupture happens, it really wouldn't take much at all to pierce a hole, especially following cardiac arrest."
He added Miss Penrice's diaphragm was "like a balloon full of water" and the tube created a ridge when resting on it, that caused the second rupture.
The drain still "effectively worked as a chest drain", Dr Oranmore-Brown said, but he told the inquest he spent countless sleepless nights trying to work out how the error had occurred.
'Futile' attempts
The consultant added since her death, he had researched the chances of liver patients like Miss Penrice surviving a cardiac arrest.
"A study I have found looks at over 1,000 patients and they had a 100% mortality rate - 80% died shortly after the cardiac arrest and 20% within 28 days.
"Everything we did after CPR was futile."
Coroner Margaret Taylor said she was satisfied Miss Penrice had died of natural causes and attempts to help her after the cardiac arrest were "heroic" but "unsuccessful".
Addressing Miss Penrice's family, Ms Taylor said: "We heard about how Julie struggled with alcohol and did a lot of damage to her body.
"Despite all the help you gave her, she was on her own path [...].
"She had a very damaged liver and really that is the start of the problems - that is what led to her death."
Speaking at the inquest, Miss Penrice's family described her as "lively and bubbly", a much-loved member of their family.
They said: "She was always there for anybody that needed her - you could rely on her."
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