Inquest: Mandy Martin died in hospital following surgery

Mandy Martin, of Glemsford Road, Lowestoft, was admitted for essential limb-saving surgery on her arm following a serious elbow fracture and two subsequent operations at the James Paget hospital, Gorleston.

She had undergone previous surgeries under regional anaesthetic but had experienced being able to feel the operation and heard surgeons talking throughout.

Her previous surgeries had taken place on October 18 and November 5, 2021, following a fall onto concrete in her garden on October 9. 

Before being taken into theatre for her third arm procedure on November 26, she was visited by anaesthetist Dr Syed Mazhar. 

Dr Mazhar gave evidence during the first day of the two-day inquest, held at Norfolk Coroner’s Court on Thursday June 29, via video link. 

He claimed Mrs Martin had initially told him she had “felt pain and discomfort” during her previous surgeries under regional anaesthetic and had revealed to him she “had felt everything”.

As a result, he talked her through using general anaesthetic for her upcoming procedure and was made aware of the “extreme anxiety” she had surrounding being put to sleep. 

Mrs Martin’s long-term friend of around 15 years, Carol Gooch, also gave evidence via video link.

She disputed Mr Mazhar’s evidence, saying her friend “had never mentioned being in pain” while under regional anaesthetic.

“She was majorly anxious,” she added. 

“She told him she was ‘scared and frightened of not waking up’ from the operation.” 

The court heard how Mrs Martin was fearful of hospitals, needles, operations, and not waking up from general anaesthetic. 

It also heard how there was a disagreement about how physically able Mrs Martin was as a chronic obstructive pulmonary disease (COPD) patient, and how her fragility was only apparent following her death. 

While Dr Mazhar said Mrs Martin told him she was “able to walk 500 yards”, her family claimed she could not, and would not have admitted to being able to.

He added: “I formed an incredible bond with Mrs Martin, and I will carry this through the rest of my life.” 

Her daughter described "an eeire conversation" with her mother before her operation.

In the statement from Kelly Mullender, she said: “Before that final operation, she rang me and told me ‘If anything happens, remember I love you’.” 

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While being given a general anaesthetic, Mrs Martin went into anaphylactic shock which subsequently saw medical professionals carry out lifesaving compressions.  

She was taken into intensive care. After a brief stable period she was moved to a ward but deteriorated and died on December 10.

The court heard how the combination of COPD and anaphylaxis led to her death and how, if treated on their own, she would have likely survived.

The inquest was led by assistant coroner, Johanna Thompson. She recorded a short narrative conclusion.

Mrs Martin, who was born in Lowestoft, was married to Barry, a builder.

Speaking after the inquest, her family said: "It has been incredibly difficult for us all as a family to hear the evidence in relation to the very sad death of Mandy, who was a much loved wife, friend, mother and grandmother.

"We miss her terribly. She was always smiling and laughing, incredibly family orientated and a beautiful person inside and out.

"We are grateful to the coroner for her focus on the issues and her determination to ascertain the facts surrounding our profound and tragic loss.

"As a family, we are encouraged that the [James Paget University Hospitals NHS Foundation] Trust has improved their policies and communication between the teams as a direct result of the circumstances of Mandy’s death.

"However, for us, it is too little, too late.

"We will now take some time to reflect on the evidence we have heard and consider our options over the coming days and weeks."