A coroner will raise his concerns about weekend staffing levels at a hospital following the death of a grandmother-of-nine after a routine hernia operation.
Margaret Gleeson, 70, died on a Sunday just two days after being admitted to Wigan's Royal Albert Edward Infirmary.
An inquest into her death was told that weekend staffing was a concern with a consultant surgeon admitting he could not give the same attention to patients.
One on-call medical team was being asked to do the job of four teams with emergency admissions taking priority and leading to delayed and shorter medical reviews of elective cases, Bolton Coroner's Court was told.
Widow Mrs Gleeson, a stewardess at her local bridge club, was described by her family as "a fit and active woman" before she went into hospital on October 2 last year.
The surgery was initially thought to have been a success but Mrs Gleeson’s condition began to deteriorate the day following the operation and doctors found that tissue in the bowel had been torn - described as "a rare complication".
The court heard an 'early warning score' used by medics to establish the risk to a patient's health had earlier been incorrectly recorded.
Coroner Simon Jones concluded that Mrs Gleeson, of Swinley, Wigan, died of cardiac arrest suffered when she was anaesthetised for surgery to repair damage from the initial operation.
He said he was satisfied there were no "gross failures" in her treatment but that evidence from a number of witnesses about weekend staffing levels were "sufficient in my view to arouse my concern".
Mr Jones said those concerns were "most vividly" highlighted by consultant surgeon Sadavasim Loganathan who told the inquest: "You don't give the same attention as the patient deserves."
The surgeon agreed it was "a major concern" and said the situation was similar at "lots of organisations in the NHS at the moment".
The Coroner said he would send a Preventing Future Deaths report - in which there is a risk of other deaths occurring in similar circumstances - to the chief executive of Wrightington, Wigan and Leigh NHS Foundation Trust.
Mr Jones said: "Although this is a national issue in terms of the National Health Service as a whole, my duty as a coroner in this jurisdiction is in regard to the Royal Albert Edward Infirmary in Wigan."
Copies of his report will be sent to the Department of Health, the National Institute for Health and Care Excellence (Nice) and the Care Quality Commission (CQC).
Following the inquest, Mrs Gleeson's son, Peter, said: “I think if she’d had the operation on a Monday or any other time in the week it would have possibly been a different outcome."
Mrs Gleeson's daughter, Julie Barnes, said “We are grateful for the coroner’s thorough investigation into the circumstances surrounding mum’s death. To say we miss her is an understatement. She was the focal point of our family and my two sisters, brother and I have lost our lovely mum and nine grandchildren no longer have the grandma they adored.
“We sincerely hope that no other family has to suffer the pain and anguish we have had to endure following mum’s death."
She said the family is pursuing a civil action against the health trust as they aim to "ensure lessons are learnt and procedures put in place to guard against such errors in the future.”
Representing the family, Stephen Jones a medical negligence expert at law firm Leigh Day in Manchester, said: “We are satisfied that, after hearing the evidence, Margaret Gleeson’s care fell below proper levels and that her death was eminently preventable.
“We are not sure of the extent to which weekend working was a factor in her death but we recognise that in view of the comments made by some of the trust’s own clinicians that local people will be extremely concerned. We therefore welcome the fact that the Coroner has asked the trust to look at this issue.”
In a statement the trust said Mrs Gleeson received attention and care from "a large number of qualified professionals" but it conceded its own investigation had revealed there were shortcomings in "some aspects of the care".
It accepted her prospects of survival would have improved if the further surgery had taken place earlier but it did not accept that weekend staffing levels played a part in her death.
It said: "The trust does not believe that Mrs Gleeson’s death was the result of any difference between the resources available and services provided at the weekend and those provided on weekdays.
"The trust already complies with national guidelines in relation to weekend working and is actively involved in an ongoing pilot scheme investigating the possible benefits which might be derived from seven-day working.
"The trust is one of five acute hospitals in the NHS who have been piloting enhanced weekend working for the last two years including an investment of an £2.1m in extra staffing."