Pregnant woman died at Queen’s Hospital, Romford after doctors mistakenly removed a healthy ovary instead of appendix
16:44 07 June 2013
A pregnant woman suffering from appendicitis died after doctors at Queen’s Hospital mistakenly removed her healthy ovary instead of her appendix.
Maria De Jesus from Wroxall Road, Dagenham died on the operating table after a second operation to remove the appendix and it was revealed that doctors had removed her ovary two weeks previously.
An inquest into the death of the mother-of-three at Walthamstow Coroner’s court yesterday (Thurs) heard that the cause of Maria’s death on November 11, 2011 was multiple organ failure due to severe sepsis brought on by oopherectomy (removal of ovary) and appendectomy.
The 32-year-old was five months pregnant when she was admitted to the hospital on October 21, 2011 complaining of abdominal pain.
She was diagnosed with appendicitis and it was arranged that she would have an operation on October 23 to remove the appendix.
But the inquest heard the operation was carried out by two trainee surgeons in the absence of a consultant surgeon who removed her healthy ovary instead of her appendix.
Eight days after the operation, the teaching assistant was discharged from the hospital, but admitted herself on November 7 when her abdominal pains got worse.
Doctors only picked up on the mistake two weeks later on November 9, when it was discovered that the histopathology report, which had been available since October 31, confirmed no appendix was seen on microscopy.
Dr Sunita Sharma told the court that she was “puzzled” about the patient’s condition and decided to look through her pathology results when she realised that her ovary had been removed instead of her appendix.
She said: “It didn’t make sense that a healthy young woman with appendicitis wasn’t recovering after the appendix had been removed.
“I looked at the results and it showed that her ovary had been removed and not her appendix. I could not believe it, I was shocked.”
Coroner Chinyere Inyama said that there was a loss “window of opportunity”.
He added: “The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.”
The day after the discovery was made, 100 mls of pus was drained from Maria’s abdomen.
Despite attempts to save her, she miscarried and died on the operating table after a second, successful appendectomy to remove the appendix.
Coroner Chinyere passed his condolences on to the family after recording a narrative verdict.
Chief executive of the Barking, Havering and Redbridge Hospital Trust, Averil Dongworth admitted liability in this case and apologised to the family.
She said: “An extensive trust wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again.”