A nurse, who dedicated 35 years to the NHS, died following hospital treatment after she was left in agony by doctors who said they had to treat 40 other patients before they could tend to her, an inquest heard.
Jeanette Bailey, 53, from Manchester was a highly regarded and caring theatre sister looking after young mothers at a maternity unit - yet medical professionals failed to monitor her care when she was receiving life-saving treatment. Despite her complaining of heart problems she was deemed unfit to undergo surgery then when she was readmitted to hospital she was subsequently given an accidental overdose of blood-thinning medication. She developed a painful condition which affected the muscles in her upper right arm and she died five weeks later.
A change of care would not have prevented Mrs Bailey's death but her family condemned medics at Manchester Royal Infirmary after a coroner said she had been subjected to unnecessary 'pain and suffering'.
Bosses have now reviewed the way they monitor the administration of the anticoagulant drug, Daltaparin.
The hearing was told Mrs Bailey who worked at nearby St Mary's Hospital in Manchester had been previously diagnosed with leukaemia but was denied a bone marrrow transplant on the NHS and had to get the operation done privately in London due to 'insufficient finds'. She had to find her own donor.
Her daughter Gemma Lawlor said outside the Manchester inquest: 'I am not satisfied with the hospital's apologies because they made her suffer for the last six months of her life. She gave her life to the NHS and to helping people who will ill but there was a lack of care and monitoring when she became ill.
'Everyone loved my mum and so many people I know who had their babies at St Mary's said how great she had been with them. But she would never tell us if she'd looked after one of my friends because she took her job seriously and cared so much about patient confidentiality.
'She dedicated her entire working life to the NHS and caring for other people and had a passion for nursing. She was a special person - a humble, genuine woman who appreciated life and lived hers to the full.
'Even when she was very ill and couldn't walk with leukaemia, she still wanted to go into St Mary's and be a nurse. She fought until her very last breath.
'I'm just happy that the doctors have made changes in procedure following mum's death and she would be happy with those changes. It does not bring her back but at least it has been recognised. My mother would be have been happy with the fact that she made the changes and knowing that she may be saving someone else.'
Mrs Bailey, from Dukinfield, a mother of three who had two grandchildren, had joined the nursing profession aged 18 after she helped care for late mother.
Miss Lawlor told the hearing: 'She trained to work as a nurse at North Manchester Hospital for 15 years before going to work as a theatre assistant at St Mary's Hospital in Manchester.
'When she turned 28 she was diagnosed with leukemia and underwent a transplant. She was denied one by the NHS due to insufficient funds and had to seek out her own doctor and he did the transplant privately and she went into remission.
'She was given the all clear at 31 years of age and for a number of years had no significant health problems. But as she got older she was told she had problems and mild angina. That then became severe but she was told she not fit enough to undergo an operation. One our concerns is why couldn't she have undergone the surgery earlier.
'The condition worsened and she became short of breath and had chest pain and whilst she was in hospital she developed sepsis. She was kept in hospital and underwent kidney dialysis until she was released. Another one of our concerns is that we believed she was still septic when she was sent home.'
Nurse Jeanette Bailey who dedicated 35 years to the NHS
Mrs Bailey was readmitted to Manchester Royal Infirmary on January 3 last year for further dialysis and she was diagnosed as still suffering from sepsis. She was then given Daltaparin for six days before any checks were made and tests showed the levels were higher than the recommended dose.
Miss Lawlor added: 'She wasn't given any antibiotics straight away. They said there were 40 more patients they had to see before my mum. She had difficulty breathing and she was pale and suffered a heart attack but managed to pull through.
'Whilst in intensive care we were informed she had been given too much blood thinning medication and she developed a condition called compartment syndrome in her upper right arm.
'She remained in hospital but deteriorated and passed away on the 18th of February 2017. We are concerned to know whether the compartment syndrome could have contributed to her death.'
Renal Consultant at Manchester Royal Infirmary David Morton said: 'I met Jeanette for the first time on January 9 in the evening and we noted that she had some small bruises on her arm.
'It was unclear how long they had been there for. I asked for an assessment of the Dalteparin blood thinning drug. The level was assessed and came back high. She began to have pain in her arm and swelling and she required a return to intensive care.
'These checks were supposed to have started on the 6th of January continued before and after every three doses administered. I am very sorry that she experienced pain and required an operation she may not have needed. I think it didn't make her any stronger and gave her a lot of discomfort.'
Pharmacist for critical care, Tony Dunne told the hearing: 'An investigation undertaken following Jeanette's death revealed between the degree of use of anticoagulant drugs in different departments and an action plan has been created which seeks to merge those two protocols.
'The investigation showed that if checks were made on the use of the blood thinner when they were supposed to be then Jeanette wouldn't have developed compartment syndrome. The issue was not how much of the drug she was given but the lack of monitoring and we are implementing a tighter monitoring protocol.'
Leonard Ebah Clinical director of Renal medicine said: 'An investigation report showed that the root cause of Jeanette's compartment syndrome was due to a failure to monitor the doses of blood thinner and care was not up to standard in terms of monitoring and we are piloting a new scheme in the way we monitor anticoagulant drugs as of two weeks ago.
Pathologist at Manchester Royal Infirmary, Dr Samar Al Habba told the hearing: 'Jeanette had a very heavy and large heart caused by long standing hypotension and an Ischemic heart for a very long time.
'The bone marrow transplant used to treat her leukaemia makes patients four times more likely to develop heart disease so she had more risk factors.
'Unfortunately her heart was in a very bad condition and the stress of the surgery meant she wasn't able to recover.'
Recording a narrative conclusion, Coroner for Manchester Jean Harkin said: 'Jeanette Bailey had very severe heart disease for a number of years and died from the heart disease following cardiac surgery.
'It is clear there was a system breakdown in the hospital in relation to monitoring. I accept the renal side of her condition and that the compartment syndrome did not contribute to her death but there was a clear breakdown which caused her pain and suffering.
'That caused distress to her family but that has been admitted and apologies have been made in open court but that does not bring Gemma's mother back. We need to make sure that these matters are monitored in future and I am satisfied by the evidence that I've heard that has been put into place. I am satisfied that there are no regulatory letters required due to the systems put in place.'
By Anthony Joseph for MailOnline