Bupa Roding Hospital death: Carmel Bloom died after medical 'absences'
Medics could have done more to save the life of a woman who died after a routine kidney stone operation, a third inquest into her death has ruled.
Carmel Bloom, 54, from Ilford, Essex, died after surgery at the privately-run Bupa Roding Hospital, where she worked.
A coroner ruled she was not unlawfully killed, but failure to perform certain actions contributed to her death.
Bupa offered condolences but said, as it no longer owns the hospital, could not comment further.
Ms Bloom died on 8 September 2002, after undergoing surgery to remove a kidney stone on 28 August.
Coroner Karon Monaghan QC, sitting at the Royal Courts of Justice, said a series of "absences" had contributed to her death.
Her "vital signs were not consistently recorded", the coroner said, despite instructions from a consultant urological surgeon they should be checked every 30 minutes, the coroner said.
Ms Bloom's blood pressure continued to fall and by 02:00 BST on 29 August she was septic, the coroner said.
The consultant urologist was not called until 02.55 and arrived 20 minutes later while the consultant anaesthetist was not called until 04.29, by which time Ms Bloom was suffering from pulmonary oedema, the coroner said.
Why three inquests?
The first inquest in 2003 found Ms Bloom died of natural causes, but that verdict was quashed by the High Court in December 2004.
A second inquest in 2005 at West London Coroner's Court found lack of post-operative care contributed to her death.
That finding, deemed inadequate by the Bloom family, was also quashed.
The family has said fresh evidence, including an expert report and a 999 call where the night sister at the private hospital described the seriousness of Carmel's condition to emergency services, should give a full picture of how she came to die.
She was rushed to Whipps Cross intensive therapy unit (ITU), Ms Monaghan QC said, but the anaesthetist did not intubate and ventilate Ms Bloom, or attach equipment which would have allowed for monitoring during the transfer.
"Shortly after arrival at ITU Carmel Bloom went into cardiac arrest. She experienced severe hypoxic brain injury and did not regain consciousness", she said.
Ms Bloom remained on life support until September 8 when the decision was taken to turn the machine off.
She died after her blood pressure fell and she had another cardiac arrest.
After the hearing, Ms Bloom's brother Bernard said: "Carmel was let down and the system has badly let down the family."
He said: "This has taken over 14 years. I could not have done this any quicker.
"It was bad enough what happened to Carmel, but what happened to the family, it is a disgrace. It is the system that needs to be amended."
A spokeswoman for Bupa, which owned Roding Hospital in 2002, said: "We sympathise with Carmel Bloom's family for their loss.
"Her colleagues at the hospital were all deeply affected by this tragic incident.
"As we no longer own the hospital, it's not appropriate for us to comment any further."