Inquest into the death of Elaine Basham concludes after a four year wait
28/09/2005
Thank you so much for handling my case so well. You came to know us at a great time of sadness and you were so kind. We will always remember you as very professional but also very warm hearted.
Sylvia, Tamworth
The jury inquest into the death of Elaine Basham, who died after a routine tonsillectomy concluded today.
Almost four years ago Elaine aged 33 bled to the point of cardiac arrest after her tonsils and adenoids were removed at North Riding Hospital, Middlesbrough.
The surgical instruments used during Elaine's operation have been the cause of much concern - they were banned in England just a month after her death. Two people are known to have died following tonsillectomy operations using the instruments.
The jury concluded that the single use surgical instruments used caused Elaine's primary haemorrhage.
Elaine had Down's Syndrome and led an active life. She swam competitively for her school in the 'special Olympics' winning a host of medals. The minor operation was elective and not because of any life threatening condition.
The following statement was read outside the court by the family's solicitor Richard Follis of Alexander Harris after the conclusion of the inquest:
"The family are relieved that the inquest is finally over they have asked me to say that they found the inquiry conducted by the coroner was very thorough.
However, it is a source of very considerable regret and concern that it has taken nearly four years to reach this point. Sadly, Elaine's father, Brian, passed away while still waiting to find out what had caused his daughter's death after what had intended to be a routine and entirely elective operation. My clients hope that no one else will have to experience such a terrible wait for an inquest.
Elaine herself was apprehensive about going into hospital to have her tonsils and adenoids surgery. She had expressed fears that she might not come out of hospital alive. She and her family though were completely unaware that she was going to be operated on with recently introduced single use instruments. They were equally unaware that by the 5th of November 2001, the date of Elaine's operation, a series of concerns had already been expressed by surgeons about the quality of these newly produced instruments.
Elaine and the family also did not know that less than three weeks earlier another patient at North Riding Infirmary needed treatment at the intensive care unit after having to go back to theatre four times because of a post-tonsillectomy haemorrhage. Had they known that, their view about surgery would have been very different.
We heard during the six and a half days of the inquest that single use instruments were introduced because of concerns by the Department of Health that in some hospitals the cleaning and sterilisation of surgical equipment was poor. Elaine's death is all the more tragic because we now know that the standards of instrument cleaning at NRI were throughout the whole of 2001 sufficiently good never to have needed to introduce single use instruments.
The family note with some concern that Professor Troop, the former Deputy Chief Medical Officer who gave evidence here, described in her evidence the introduction of single use instruments as an interim measure. This was surprising, considering that five years funding the single use instruments had been secured by the Department of Health from the Treasury and some £25m of funding was put in place to provide a five year supply.
Elsewhere the introduction of single use instruments was described as a pilot project rather than an interim measure. Whatever it was there is little doubt that for nearly 12 months after the government announced, amid a great deal of publicity, that these single use instruments were going to be used, that there were really serious doubts about the quality of the equipment that was being supplied and as a result of problems with equipment quality, as Professor Troop herself said - "patient safety was compromised."
In exchange for removing the theoretical risk of infection with variant CJD a real risk was created, namely the use of instruments which were not of sufficient quality.
Elaine's mother's recollection is that Elaine was struggling for breath, spitting out blood from her throat and complaining she was choking when she was taken into the anaesthetic room at about 8.30pm.
Elaine then lost consciousness when she was made to lie back.
During the evidence staff from the hospital gave conflicting accounts of what led up to Elaine's first collapse. At least one member of staff gave evidence, which Mrs Basham saw for herself, which is that Elaine collapsed and had a cardiac arrest when she was trying to breath but was made to lie back.
There are also concerns about the delay in providing treatment for Elaine shortly after 1am when she was deteriorating due to a blockage in her artificial breathing tube. While waiting for surgeons to arrive Elaine suffered a second cardiac arrest.
Having heard the evidence the family are satisfied that had it not been for the introduction of single use instruments Elaine would not have suffered any of the complications which led to her tragic death."
Notes to Editors:
- The family have requested that all contact from the media should be made directly to the media management department at Alexander Harris on 08700 77 88 77.
- Interviews with the family are not available - they are happy for their solicitor, Richard Follis to speak on their behalf - all requests should be made to the media management department.
- A photograph of Elaine approved by the family is available - please contact the media management department for a copy.
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