Treatment of tragic mother-of-two substandard: coroner
Mother-of-two Lynn Lewis (38) died at the Ulster Independent Clinic on July 7, 2011.
The Co Armagh woman was to undergo a relatively minor procedure, known as transcervical endometrial resection, to remove a large, benign fibroid from her uterus.
Professor Neil McClure led the team in the operation, which he conducted in his private professional practice.
But within 10 minutes of starting the operation, Prof McClure discovered that the fibroid was much larger than expected.
Mrs Lewis experienced two heavy internal bleeds and irrigation fluid was used to help the surgeon have a clear vision in order to stop the haemorrhage.
However, she died three hours later.
Mrs Lewis was found to have died from a combination of haemorrhage and hyponatraemia. Senior coroner John Leckey noted that she would most likely have survived the haemorrhage.
He was severely critical of the entire surgical team, speaking of "personal and institutional failings" in the treatment and care of Mrs Lewis, finding it to be "sub-standard".
"Whilst I accept that no medical procedure is risk-free, I have no doubt that Mrs Lewis would not have died if the appropriate measures and precautions had been taken," said Mr Leckey.
He accepted a co-signed statement from the surgeon, the anaesthetist Dr Damien Hughes and Ulster Independent Clinic and its nurses, each accepting individual responsibility in their failures during the operation.
Prof McClure admitted he should have abandoned the operation if and when blood results became available indicating hyponatraemia.