THE trust in charge of the Alexandra Hospital said it had ‘learnt its lesson’, after an inquest into the death of popular district councillor Peter Lammas found he had died from sepsis following an operation.

Former Advertiser chief reporter Mr Lammas, known affectionately in his hometown as ‘Mr Bromsgrove’, tragically passed away on October 22 last year, aged 71.

A post-mortem examination discovered a five-litre mass of bloodstained fluid – or hematoma - in his abdomen, and a severe infection in his kidneys.

An inquest was launched to determine his precise cause of death.

After being diagnosed with prostate cancer in October 2014, Mr Lammas had his prostate surgically removed ‘without incident’ in Redditch on August 23, 2016.

He was discharged two days later but was readmitted with a urinary tract infection on August 30.

His health continued to deteriorate until he eventually died at the hospital nine weeks later.

During a two-day-long inquest at Worcestershire Coroner’s Court, a jury heard the results of a ‘Serious Incident Investigation’ launched by Worcestershire Acute Hospitals NHS Trust, which found that blood-thinning drugs had been administered on two occasions when Mr Lammas was not in a suitable condition to receive them.

Consultant urologist Vincent Koo, who conducted the investigation, explained how Mr Lammas regularly took warfarin – a similar medication – to manage recurrent deep vein thrombosis, and that a substitute was ‘reasonably’ given in hospital until September 1.

At this point however, his blood was thinner than the recommended level, but the information was not effectively communicated to other hospital staff, meaning the normal dose was given again, followed by another smaller dose the following day.

“It should have been stopped,” said Mr Koo. “All clinicians tried their best but we have learnt our lesson.

“It’s very easy to look back with a retrospective scope and say we should have done differently, but there is no ‘one shoe fits all’.

“As clinicians, we have to make difficult decisions about what is best for that specific patient.”

Asked by assistant coroner David Reid if the medication had played a part in Mr Lammas’ demise, Mr Koo said it was a ‘contributing factor but not a direct sole cause’.

When readmitted, Mr Lammas was suffering from an infection and kidney dysfunction, which likely contributed to the formation of the hematoma, placing him at greater risk of developing further infection.

Despite two CT scans, a source of the internal bleed was not found, nor was it discovered during the post-mortem exam.

It was likely caused by infection and stemmed from smaller blood vessels that failed to heal after his operation, Mr Koo told the court.

Nonetheless, the trust has since changed the way it records and displays blood thickness (INR) levels for patients who have recently received warfarin therapy.

The jury recorded Mr Lammas’ medical cause of death as 1a sepsis, caused by 1b acute pyelonephritis and renal abscess (kidney infection).

Hematoma following prostate surgery and warfarin therapy for vein thrombosis were listed as secondary causes.

The overall verdict was ‘accidental death’ and the inquest was closed on July 28.

Speaking after the result, Mr Lammas’ son Andy, 47, said: “My family is quite happy with the verdict and happy that these proceedings have finally come to a close so we can start moving on.

“Obviously there were some misgivings, but as a family we’re happy that the trust has made these changes to prevent another family going the same agony and stress we have. That’s what my father would have wanted.”