After the first surgery at the Alexandra Hospital she was subjected to physiotherapy involving blowing hard into a peak flow meter: This undoubtedly either caused or contributed to the breakdown of the tissues around the operative site. It is unclear as to who ordered this physiotherapy, as the surgeon and the anaesthetist both indicated that did not do so and would not have done so. During surgery to repair the oesophageal pouch; there were a total of three attempts to site an endo-tracheal tube and on each occasion it failed_ Part of the reason for this was that it was found that the batteries for the fibre optic tube were flat and inoperable. No replacement could be found. averred that never a light source at all" during the operation: This is an unacceptable situation during_a critical operative they "we got procedure: He then went on to say The need for an endoscope was critical and this is now a panic situation with the possibility of something going catastrophically wrong" Whilst the patient was in theatre for the emergency procedure, her family were advised to wait in the restaurant or reception areas of the hospital: As they were waiting; heard one of the porters shout out "we have got a cardiac arrest in theatre. This caused them extreme distress and alarm_
5. After the first surgery had taken place; the family noticed there was a and very obvious swelling around the neck and face of Mrs Harrison: did the nurses not note this and act upon it earlier?