The resident doctor looking after Mrs A said he ha

The resident doctor looking after Mrs A said he had suggested the problem might be a perforation of the bladder but Barker dismissed the idea.

Wolfgang Wallat, then RMO at the 30-bed New Victoria Hospital, told how it was ‘terribly obvious’ in hindsight.

He added: ‘I feel very, very bad about Mrs A dying.

I did not expect her to die and I did not anticipate this outcome because she was a fit, healthy lady.

‘Looking at the notes it looks terribly obvious what might have been the cause and the chain of events, but at the time I certainly did not anticipate that she was going to die like that.

‘

Dr Wallat said he believed Mrs A was suffering from urine retention and that it got better after the catheter was first inserted on February 20, 1993.

He added: ‘I pretty much thought the problem had been solved.

After that I was happy with her condition.

‘

The next morning the painkillers were stopped but as soon as the catheter was taken out the problems recurred.

Dr Wallat said: ‘I was surprised that she had pain again but I was not particularly concerned about her condition.

‘At the time I believed it was because she was frightened.

‘

He phoned the consultant Barker and discussed the case at 7.

30pm on February 21.

Dr Wallat said: ‘The brain clicked and on the phone I thought maybe could it be that it was a perforation.

In the conversation it came up but that is as far as it came out.

‘

On the morning of February 22 he was confident enough not to not warn the doctor taking over his shift at 8am even though Mrs A was taking antibiotics for suspected septicaemia, the committee was told.

Dr Wallat said: ‘I expected her to get better and improve.

I asked the next doctor to keep an eye on her but I did not say I thought she was seriously ill or anything like that.

‘

Barker decided to carry out his operating list at 8.

30am and Mrs A died five hours later after suffering a cardiac arrest.

The hearing continues.

ends