A WOMAN who had two previous episodes of meningitis died after a routine operation at Hereford County Hospital.

Christina James, from Cherrybrook Close in Hope-under-Dinmore, near Leominster, was admitted on January 6, 2022 for endoscopic surgery to her nose.  

However, the 63-year-old failed to wake up and was transferred to Queen Elizabeth Hospital (QE) in Birmingham for further care. 

Dr Thant, who works at the QE, said that on March 9, 2022, Mrs James underwent a period of drainage to protect the repair and was stable - opening her eyes and answering to commands. 

However, he said that on March 31, 2022, she became acutely unwell and had respiratory failure.

"She was deemed not to be fit enough for future ITU management," said Dr Thant. 

"She deteoriated further and died on April 3."


Dr Thant recorded Mrs James' cause of death as being hospital acquired pneumonia; subarachnoid haemorrhage and anterior cerebral artery pseudoaneurysm; functional endoscopic sinus surgery and polypectomy; and morbid obesity.

Katherine James, Mrs James' daughter, told the inquest that her mother was nervous as she waited for the operation.

"She was just fed up with waiting, she just wanted it over and done with," she said.

"She knew she had polyp in the right nostril - she thought that was being removed.

"We were told we had to take her in, leave her and go out."

A serious incident review was carried out by Wye Valley NHS Trust (WVT) with a round table meeting taking place the following month.

The inquest heard that Mrs James had a history of morbid obesity and had two previous episodes of meningitis.


However, Simon Prowse, a consultant ear, nose and throat surgeon at WVT, said that he was unaware that she had the condition.

"When I met Mrs James on January 6, I received notes on an electronic system and letters that this lady had right ear pain," said Mr Prowse.

"When I received the patient's notes, there was no mention of menigitus. 

"The GP records are kept on a separate system."

The inquest heard that Mrs James sustained a bleed to her brain as a result of the surgery, and what she had was extremely rare.

"There were only 12 reports cases in the world - Mrs James was the 13th," said Mr Prowse.

"Mrs James arrived in hospital in her usual health and left in an ambulance. I am sorry for the loss."

The consultant said that the operation was performed by a registrar and everyone present could see the surgery being performed on a screen.

"Something happened in the procedure, undoubtedly," said Mr Prowse.

"I am now more vigilant with oddities - it has affected my practice."

Dr Robbie Dedi, deputy chief medical officer at WVT, said that, since Mrs James' death, the trust had carried out a number of action plans, all of which had been completed. 

Mark Bricknell, senior coroner for Herefordshire, recorded a narrative conclusion.