An inquest into the death of a woman, who died from complications from an operation her family claim she shouldn’t have undergone, has concluded and found that “significant errors of judgement” from one doctor played a part in her death.

Spencer Collier, head of our medical negligence team, represented the family of the 66-year-old woman at the inquest at Nottingham Coroner’s Court.

The patient had suffered a haematoma and a stroke caused by a bleed on her brain and was transferred from King’s Mill Hospital’s emergency department to Queen’s Medical Centre’s neurosurgery ward for more specialist care in July 2023.

The inquest heard evidence that suggests that her condition was relatively stable on arrival at Queen’s and that no operations for the patient were planned or authorised by a consultant neurosurgeon.

The on-call consultant at Queen’s gave evidence to say that he had a call with the neurosurgery registrar at Queen’s during which it was decided to only observe the patient. Dr Cyril Okpata, a Junior Doctor at the same hospital was present during this conversation. No decision about surgery was made at that time because it may not have been necessary if the clot dissipated over time. Dr Okpata claimed however that he was told there was a decision to operate for clot extraction within the hour, and that he was told to “get on with it”.

Dr Okpata had never performed this kind of surgery unsupervised before and did not make the on-call consultant aware of the operation or contact him when he found the surgery challenging.

The inquest heard that Dr Okpata carried out the surgery at the wrong angle and site, causing the patient brain damage, which Dr Okpata accepted. It is also heard that he used the wrong tool for clot extraction, using a dandy cannula, rather than a small incision and sucker to remove the clot.

Following surgery, her condition deteriorated, and she required a second, lifesaving operation, which led to post-operation complications that caused her death.

An internal investigation report by Nottingham University Hospitals NHS Trust, which was presented at the inquest, concluded that Dr Okpata should have contacted the on-call consultant again before proceeding with surgery and asked for his assistance during the operation due to his inexperience and the difficulties he faced.

Following evidence, HM Coroner concluded that the patient died from consequences of infection arising from operations to remove a clot in the brain.

He found that the first procedure by Dr Okpata had no appreciable impact on the clot and resulted in damage to the patient’s brain and deterioration of her condition. He concluded that following the second operation, the patient developed a blood infection while in ITU which spread to her brain, and that her subsequent death was caused by both the first operation and infection.

He added that there were “significant errors of judgement” by Dr Okpata in relation to the patient’s care.

Following requests from the family, HM Coroner confirmed he will contact the General Medical Council (GMC) to express his concerns about Dr Okpata and his behaviour before, during and after the operation, and at the Inquest itself.

Speaking after the Inquest, the family’s Solicitor Spencer Collier said “This has been a devastating set of circumstances , which was totally avoidable. The management plan was clear and the Consultants who gave evidence at the Inquest confirmed this. We will be contacting the Trust inviting them to admit liability, failing which proceedings will be issued. Our condolences remain with the family”