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

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

Worcester pathologist, Dr Paul Dunn said leakage was common after the surgery on the pensioner.

Tumour

Sixty-six-year-old Mr Bramley, of Queens Court, 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 very 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 'simply would not have survived in his condition'.

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

"In usual circumstances leakage was indicated by poor health in the patient but Mr Bramley appeared to be recovering well," he continued.

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