AN eminent surgeon described yesterday how a patient died after losing nearly 22 litres of blood - four times her body's volume - during a routine operation that went wrong.

Jean Edna Douglas, 64, died after doctors tried for an hour- and-a-half to save her after a small vein ruptured during an operation on her bowel.

Gateshead coroner Terence Carney ruled yesterday that Mrs Douglas' death, at the Queen Elizabeth Hospital, Gateshead, last May, was caused by misadventure.

He said it was not clear how the vein had torn and it was not his job to apportion blame.

Jane Wright, representing the family, said while they felt Mrs Douglas' death had been "avoidable", a civil case would not be pursued, because of difficulties in clinical cases.

Consultant surgeon Mr William Cunliffe, who is an acknowledged leader in his field, said Mrs Douglas, of Allerdene, Gateshead, had been admitted with a prolapsed rectum.

He said he had never had a patient who had not survived the operation he carried out on her, and had told Mrs Douglas there was a "less than one per cent risk" of anything going wrong.

But, after a second stitch during the operation, he noticed blood appearing and applied gauze packs to staunch the flow. When this did not work, he called for the help of a fellow surgeon and surgical drawing pins were used to try to control the bleeding.

But the bleeding worsened and nearly 22 litres of blood was transfused before Mrs Douglas died.

Mr Cunliffe, who is the co-author of national guidelines on the treatment of colon cancer, said it was only after dissection that it became apparent that a very thin vein had split diagonally, but he could not conclude how it had occurred.

He said: "In my 25 years as a surgeon I have never had bleeding occur in this fashion."

Pathologist James Henry said Mrs Douglas had died of shock brought about by severe loss of blood, which resulted from the haemorrhage of a pre-sacral vein.

Gateshead Health NHS Trust medical director Mario Abela said last night: "We would like to extend our deepest sympathy to the family of Mrs Douglas.

"Representatives of the trust have already met with the family, who are, understandably, very distressed.

"Today's inquest has looked into the circumstances of this tragic event and we will respond to any recommendations made by the coroner."