A coroner has ordered further investigations into how a patient died from massive blood loss after an operation at Bradford Royal Infirmary.
Cancer sufferer Victor Dewhirst died in May last year, the morning after surgeons removed his right lung.
An inquest heard how Mr Dewhirst, 62, of Queen's Road, Bradford, had eaten breakfast and was sitting in a chair having an X-ray when he "just went very white", collapsed and died.
Surgeon Alan Mearns, who has since retired, said the blood loss into Mr Dewhirst's chest was "a no-win situation".
At the inquest in Bradford yesterday a statement from Staff Nurse Annaliza Tacardon told how the operating theatre did not have the right staples needed to close Mr Dewhirst's pulmonary artery so Mr Mearns said he would "stitch" instead.
Giving evidence, Mr Mearns said he had carried out about 400 lung removals and in about 80 to 100 of them he had used stitches, in the remainder he had used staples.
But he said he had 30 years' experience of suturing vessels in chests.
Mr Mearns also said there was "only a fortnight to go", at the time of Mr Dewhirst's operation before the cancer theatres at BRI were closed and the service moved to St James's Hospital in Leeds.
He said: "We were basically clearing out all the stocks. We would only take the big equipment with us."
Cynthia Hocklea, an operations director at BRI, said theatre staff should have been responsible for checking levels of stock but said it was a possibility no one had checked the staple supply.
She said Bradford Teaching Hospitals Trust had since carried out a review of its theatre ordering systems and introduced an electronic system which alerted them when staff needed to re-order certain supplies.
Pathologist Dr Karen Ramsden said the post-mortem examination found Mr Dewhirst's pulmonary artery "completely open" and although there was still a ligature round it, the suture that looped round the artery had slipped.
Mr Mearns told the inquest the pulmonary artery was an elastic-like vessel and that he had to accept his sutures were not tight enough but stressed if he had been too rough with the artery it could have torn.
He said: "My closure was adequate at the time but there's been enough slack in it for some kind of pull-back in the vessel to occur."
Mr Whittaker adjourned the inquest for further investigations after independent medical expert Francis Wells, a consultant cardiothorasic surgeon at Papworth Hospital, Cambridge, raised the possibility a surge of blood pressure might have led to the blood loss which he described as "tragic, extremely bad luck".
After the hearing, Mr Dewhirst's widow Linda, 54, said her family's search to get an answer into why he died would continue.
She said: "We can't move forward. All we want to know is the truth. Victor was a bubbly, happy-go-lucky man with three grandchildren who he adored.
"It's been a horrendous 16 months."
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