NEW “safer” recording systems have been introduced at the Royal Bolton Hospital after a guide wire was left in an elderly woman during surgery.

June Wright, 91, died of sepsis last June after medical complications that arose while she was being treated at the hospital between February and June that year, originally with a fractured left neck of femur.

Coroner Catherine Cundy found “on the balance of probability” Mrs Wright developed the infection on February 28 when a guide wire advanced through the pelvis and into her abdomen.

But no record of this was made in the operation notes and it was not flagged with medical or nursing staff or with Mrs Wright’s family.

In a prevention of future death report, addressed to the Bolton NHS Foundation Trust, the coroner said: “I was advised that all clinical staff are supposed to make records in the electronic notes and that no handwritten records are now kept.

“I heard evidence that staff therefore have to rely on memory, or notes written on scraps of paper, until such time as they can access the electronic records on a computer.

“This case provided several instances in the care of a single patient where either no notes were made at all of clinical discussions or management plans, or crucial information was omitted.

“I am concerned that the issues of availability, workability and accessibility of IT equipment for such recording (in the context of a reliance on paperless working) creates a risk of future deaths to other patients where crucial information may go unrecorded.”

The guide wire penetration was not detected until Mrs Wright returned to the hospital for wound washout treatments on March 19 and 22.

She remained an in-patient at the hospital until April 30, 2021, when she was discharged to a nursing home on intravenous antibiotics.

Following a deterioration in her condition she was readmitted to hospital on May 30.

She was treated for suspected pneumonia before being discharged again to the nursing home on June 9 where she died seven days later.

Ms Cundy’s report, written after the inquest concluded at Bolton Coroner's Court on December 15, said it was “unclear” whether earlier recognition of the source of infection would have improved her chances of survival but that failing to take proper notes could prove dangerous to future patients.

She said: “In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action.”

In response, officials from the NHS trust says a new system has been introduced as ordered.

A trust spokesman said: “Our thoughts and sympathies remain with Joan’s family and friends and we offer an unreserved apology for where the care we provided fell short of our high standards.

“We have implemented a safer electronic record system, in line with national policy, and continue to invest in our IT hardware, to minimise the risk of this incident happening again.”