A FAMILY is distraught after a dad-of-two who underwent a routine operation died after an intravenous drip was wrongly inserted in his neck.

An inquest heard how Paul Shaw, 50, suffered a stroke after the drip was placed into his carotid artery, which carries blood to the brain, instead of his jugular vein, which goes to the heart, while receiving treatment at Royal Blackburn Hospital in May.

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But a hospital chief said the procedure followed national guidelines.

Dr Ian Stanley, interim medical director at East Lancashire Hospitals NHS Trust, said such incidences are very rare, but they are a known complication of this type of procedure.

Coroner Michael Singleton ruled the death was an accident but Mr Shaw's family say they do not accept the verdict and are seeking legal advice.

Dr Jodie Wilkinson, who inserted the line has since left the hospital to take up a position in Canada and was judged to have ‘misinterpreted information available’.

Blackburn Coroner’s Court heard how Mr Shaw had been admitted to the hospital on Tuesday, May 20, for an elective routine surgery on a large incisional hernia.

The former commis chef, who lived at Thistle Manor in Edisford Road, Clitheroe, was kept in hospital after his blood pressure dropped and developed problems with his abdomen.

Mr Shaw then vomited several times and became 'severely unwell'. He was transferred to the Critical Care Unit and 'evasive intervention' was used to stabilise his condition which involved inserting the drip on Thursday, May 29.

The error was spotted by Dr Suprea Chipcopcam several hours later but Mr Shaw died later on Friday, May 30.

Dr Stephen Mills, the independent pathologist who carried out the post-mortem examination, said that the cause of death was a stroke which was caused by a blood clot which occurred after the insertion of the vascular line.

Speaking after the inquest Mark Shaw said: “It's been a difficult time for the family and still at times difficult to comprehend.

“The least I would expect is that lessons are learned from this and that measures are put into place to avoid this happening again.

“A verdict of accidental death does not reflect the tragic set of circumstances leading up to Paul’s death.

“We are unsatisfied with the verdict and angry that we have not been apologised to by the trust.

“I would like the trust to learn from their mistakes.

“The whole family miss him very much and it will take a long time to even start to try to get past this.”

Mr Shaw, who was estranged from the mother of his children, moved to Clitheroe 10 years ago.

In a statement to the inquest Dr Wilkinson said: "On May 29 I was the consultant on call for the Critical Care Unit at the Royal Blackburn Hospital.

"Mr Shaw was on Ward C14 and he had been vomiting several times.

"He had developed severe respiratory distress and had breathed in some of the vomit.

"His CO2 levels had risen and I felt he required transferring to the CCU in order for his condition to be stabilised.

"He was severely unwell and was vomiting large amounts of brown fluid.

"He had a respiratory rate of 40 and it was not safe for him to be transferred to have a CT scan."

Dr Wilkinson said that Mr Shaw was hard to ventilate.

Recording a conclusion of accidental death, Michael Singleton, coroner for Blackburn, Hyndburn and the Ribble Valley, said: “It’s clear that Dr Wilkinson didn’t have any doubts about anything and that she was completely convinced that she had done the right thing.

“It’s only when others came along that it became apparent that it was not the case, with catastrophic consequences.

“It was a tragically simple set of circumstances and this is not a complicated inquest from that point of view.

“What it came down to was misinterpreting the information that Dr Wilkinson had.

“It was not one thing that happened; it was a number of things that somehow lined up.

“It was as if events conspired against Mr Shaw.”

He said that once the drugs were administered, there was nothing that could have been done to save his life.

Dr Stanley said: “This was a tragic incident for all concerned, and our thoughts are with Mr Shaw’s family and friends.

“Such incidences are very rare, but they are a known complication of this type of procedure.

“National guidelines were fully complied with.

“We carried out an internal investigation after the incident and as a result, we immediately put in place extra safety measures, in excess of national guidelines, to further reduce the risk of this happening again.

“As a practising intensive care consultant, I have confidence in these extra measures and the fact that they are now operational within our Critical Care Unit.”

Russ McClean, of East Lancashire Patient Voices group, said: “I’m very angry at the verdict and what has happened. I think the whole thing is really appalling I hope that nothing like this ever happens again. I intend on taking this up with the new chief executive of the trust as soon as I can.”

Dr Tom Smith, the Lancashire Telegraph’s medical expert, said: “When you are a medical student you are warned against inserting something into an artery instead of a vein.

“It’s a complete disaster and a doctor’s worst nightmare. It is a big thing to go wrong.”

John Bennett, a partner at Forbes Solicitors, who have offices in Accrington and Blackburn, said: “This is a very rare case and I’ve not come across anything like this before personally. The family could challenge the coroner’s verdict via a judicial review.”