A WOMAN died from unusual complications after routine treatment for breathing problems.
A Huddersfield inquest was told doctors had performed a simple procedure to put a tube into 72-year-old Judith Lee's chest to take away fluid which had built up near her lungs after a bout of pneumonia.
It worked at first, but Mrs Lee, of Netherthong, died just hours after the tube was removed last June 15.
The hearing yesterday was told that she died of a heart attack caused by heavy bleeding in her chest cavity.
The bleeding was caused when the tube damaged a blood vessel.
Coroner James Turnbull recorded a verdict of accidental death.
Doctors who treated her at Huddersfield Royal Infirmary were shocked by her death because they had never heard of such problems being caused by a chest drain.
Mrs Lee had been waiting for an operation to correct a defective heart valve and had been suffering from episodes of pneumonia and breathing problems.
She was having chest pains and trouble breathing when she was admitted to HRI on June 11.
A doctor inserted the drainage tube.
He was in training, but was supervised by a specialist registrar, who found no fault with the procedure.
Mrs Lee started to feel better and on June 15 the same doctor removed the tube. He was again supervised by the specialist registrar.
Soon afterwards, Mrs Lee fainted and her health got worse.
But her symptoms kept changing and baffled doctors saw no signs that she was losing blood.
The inquest heard that only surgery could have saved her life - but a specialist surgeon was unavailable.
Doctors said that even if a surgeon had been available Mrs Lee was too ill to be moved and the operation would have had to be done at her bedside.
Mr Turnbull said: "It would have been a dangerous procedure. I understand the dilemma in which the doctors were placed."
He said it was hard to see how the soft drainage tube could have damaged Mrs Lee's blood vessels, but that was definitely the cause of the bleeding.
Mr Turnbull said Mrs Lee's blood vessels could also have formed in an unusual way, leaving them vulnerable to damage.
He said he could not find evidence that medical guidelines were inadequate or that doctors had not followed them properly.
He added: "The doctors are clearly very distressed by what happened, which was totally unexpected, out of the experience of them and other doctors in a similar situation.
"That, of course, doesn't help Mrs Lee's family, nor relieve their grief.
"This is an example of an investigation which leaves more questions than have been answered."