A woman died from a rare flesh-eating disease after her treatment was delayed by bed and staff shortages at an Oxfordshire hospital, an inquest heard.
Linda Cyphus, 41, died in September shortly after undergoing a hernia operation at The Horton Hospital in Banbury -- part of Oxfordshire Radcliffe Hospitals NHS Trust.
An inquest jury on June 5 recorded a verdict of death by misadventure. They heard her death was aided by a failure of a system at The Horton that monitored the deterioration of patients.
A catalogue of problems emerged during the inquest.
Mrs Cyphus' condition -- necrotising fasciitis -- was not immediately picked up, despite several people complaining of a rotting flesh smell around her.
When a doctor did suspect she was seriously ill and requested advice from a consultant, his message was presumed not to be urgent -- causing a further delay of 11 hours.
She then spent five hours waiting for an operation because the hospital's recovery room was full.
After the operation, Mrs Cyphus had to be transferred to the Gloucestershire Royal Hospital, in Gloucester, because no intensive care beds were available in Banbury.
The inquest at Gloucester Coroner's Court was told that The Horton was only staffed to deal with one critically ill patient at a time.
The court was told that Mrs Cyphus might have lived if she had been operated on earlier and that nurses should have reported a deter- ioration in her condition the day before she died.
The hernia operation was carried out on August 28 last year. Mrs Cyphus, of Brackley, Northamptonshire, was readmitted to The Horton on September 10 after antibiotics described by her GP, Dr John Harrison, to treat what he believed was a skin infection, had no effect.
On September 17, Dr Peter Safranek, a specialist registrar at The Horton, saw Mrs Cyphus during his ward round and was concerned about her condition. He asked consultant surgeon Najam Dehalvi to examine her but did not say the matter was urgent.
Gloucester coroner Alan Crickmore said: "If the right words had been spoken by Dr Safranek, earlier action would have been taken."
Mrs Cyphus died eight days later.
Pathologist Keith Cartwright said the only treatment for necrotising fasciitis was surgery to cut away dead flesh. He said 12lb of flesh was cut from Mrs Cyphus's abdomen, side, and back.
He said: "It was clearly a life-threatening operation and Mrs Cyphus was very ill at the end of her surgery. She needed intensive care but no beds were available at The Horton.
"She was critically ill when she left Banbury. There was no way she could have lived."
He said necrotising fasciitis was a rare condition that could spread through a body at a rate of inches per hour and had a mortality rate of nearly 30 per cent.
John Scurr, a consultant at the Gloucestershire Royal Hospital, said the hernia operation had been carried out properly and that Dr Harrison was right to give antibiotics.
But he added: "I would have been concerned on September 15 when the blisters appeared, and I would have operated when they started to weep on the 16th.
"I would have expected an abscess, not necrotising fasciitis.
"The smell on the 16th was recognisable as a gangrenous odour and I would have expected nursing staff to have alerted a doctor.
"I'm not pointing the finger at any individual, but it was the system that failed Mrs Cyphus. Staff at The Horton were stretched and there were delays."
Summing up the evidence, Mr Crickmore said there was no criticism of individual staff at The Horton. He asked the jury to bear in mind the realities of life in a hospital.
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