A trainee nurse suffered three heart attacks and died after medics failed to correctly insert a breathing tube while she was in hospital with pancreatitis, an inquest heard.
Jodie McCann, 22, was starved of oxygen following "serious" failings in her care at Queen’s Hospital in Burton-upon-Trent, Staffordshire.
The inquest was told that the young mum-of-one had just started training as a nurse when she was admitted to hospital with gallstone pancreatitis on March 16 last year.
She suffered a cardiac arrest while undergoing treatment and was rushed to intensive care where she was placed on a ventilator.
A coroner heard how a breathing tube then became displaced on April 2 and medics struggled to reinsert it properly and establish an airway.
Jodie, of Newark, Nottinghamshire, was pronounced dead just before 6am after being deprived of oxygen and suffering two more cardiac arrests.
Coroner Elizabeth Didcock, found there had been “serious issues of care” and it was likely Jodie would have lived if her breathing tube was successfully reinserted.
She said the correct equipment was also not available and there was a delay in contacting a consultant anaesthetist when Jodie’s tube was displaced.
Her family have now spoken of their heartache after the coroner ruled ''serious omissions" in her care contributed to her death.
Mum Sloane Warbrick, 41, said: “It’s almost impossible to find the words to describe our loss and what the last year has been like without Jodie.
"Not only was she my eldest child; she was also my best friend. It’s still difficult to try and understand how she went into hospital and never came home.
“Jodie was beautiful inside and out. She always saw the best in people and went out of her way to help others. That’s why she wanted to become a nurse. There’s not a day goes by where we don’t think of Jodie. Life will never be the same without her.
"The inquest and listening to the evidence around her death is something no parent should have to go through but it was something I had to do not only for Jodie but for [her son] Freddie. That she’s not here to see him grow and won’t get to celebrate life’s milestones is the hardest thing to accept. Jodie would be so proud of Freddie.
"While he’ll grow up without his mum in his life he’ll always be told how much Jodie loved him and how she’ll always be a part of our family. I just hope that by speaking out improvements in care can be made. I wouldn’t wish what our family are going through on anyone.”
Jodie, originally from Salford, Greater Manchester, was first admitted to Kingsmill Hospital, Sutton-in-Ashfield, on March 16 last year.
But she suffered a cardiac arrest on March 18 and was resuscitated after 17 minutes.
The coroner said Jodie’s cardiac arrest was likely caused by her airway becoming obstructed by a combination of pain relief which affected her breathing, the pain and stress of her gallstone pancreatitis and her raised BMI.
Jodie was admitted to intensive care before being transferred to Queen’s Hospital on March 22.
Six days later medics tried to bring Jodie off the ventilator but she started struggling to breathe for herself.
A decision to re-insert a breathing tube and put Jodie on a ventilator was taken.
The inquest was told that the procedure was difficult and Jodie suffered further hypoxia – where she was starved of oxygen - and trauma to her upper airway.
Medics then struggled to reinsert the breathing tube properly before Jodie tragically passed away on April 2.
The coroner recorded a narrative conclusion and found Jodie died following a prolonged cardiac arrest caused by a lack of oxygen when her breathing tube became displaced.
She said she planned on issuing a prevention of future deaths report calling on University Hospitals of Derby and Burton NHS Foundation Trust, to set out what improvements it would take.
Rosie Charlton, an expert medical negligence lawyer at Irwin Mitchell, representing Sloane, said after the hearing: “Understandably attempting to come to terms with Jodie’s death and the truly tragic nature of what happened has been incredibly difficult for Sloane and the rest of her family.
“Not knowing all the facts about what happened to Jodie has made trying to grieve for her all the harder.
"While nothing can make up for the hurt and pain the family are going through, the inquest has been a major milestone in being able to provide Jodie’s loved ones with the vital answers they deserve.
“Sadly the inquest has found areas of concern in the care Jodie received and we urge that lessons are now learned to improve patient safety.
“We continue to support Sloane at this distressing time.”
University Hospitals of Derby and Burton NHS Foundation Trust today apologised for the failings in Jodie's care.
Dr Sreeman Andole, interim executive medical director, said: "Jodie needed and deserved a far better standard of care than was provided to her and we are truly sorry for these failings.
"Our commitment to Jodie's family and our community is that we will build on the changes we have already made, and learn from Jodie's tragic case.
"We accept the coroner's findings in full and we have a clear action plan in place to continue to address the concerns and make the further improvements needed as a priority."
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