A UNIQUE problem not recorded in any medical literature proved fatal for a Ledbury pensioner, an inquest heard.

Doctors who treated Lionel Bramley had never seen the type of peptic ulceration of the aorta that caused cardiac arrest two week after surgery in May.

Worcester pathologist Dr Paul Dunn said leakage was common after the surgery on the pensioner. Mr Bramley, 66, of Queens Courts, originally had an operation on May 19 to remove a tumour from his oesophagus and he appeared to be recovering.

Dr Rob Davies saw Mr Bramley at home on June 4 and he appeared to be doing well. Within 18 hours, he was readmitted as an emergency to Hereford's County Hospital.

Consultant surgeon Andrew Corfield said the situation was 'not redeemable'. He had never seen the type of hole in the aorta that claimed Mr Bramley's life.

He could not find it as a written complication in literature which, to him, made it 'extremely rare'.

Mr Corfield said even if surgeons had operated again as soon as they realised something was wrong, Mr Bramley could not have survived.

County coroner David Halpern confirmed that Mr Bramley died on June 5 from a gastro-intestinal haemorrhage contributed to by the erosion of the aorta after surgery.

"Because this death occurred in respect of or following on from an operation I return a verdict of misadventure," he said. There was no criticism of medical staff.