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A woman died during an operation after an unexpected power outage at Scunthorpe General Hospital meant doctors were unable to complete critical heart surgery until power was restored.
Jean Dye, 77, was undergoing a procedure to treat heart disease on 7 September 2020, when a "sudden and unexpected" loss of electricity to the treatment room meant surgeons were unable to use vital equipment, the coroner's report states.
The power loss came as the surgeons were aiming to repair a tear in an artery caused during the operation, something the coroner recognised as "a rare but recognised complication of the procedure".
The outage, which lasted for 10 minutes, meant the surgical team could not use real-time x-rays which were required to insert the stents (mesh tubes which are inserted into blood vessels to hold them open).
Once an engineer arrived and restored the power, the stenting was then completed. However, the report, by Paul Smith, senior coroner for Greater Lincolnshire, states that "Mrs Dye failed to recover and her death was confirmed."
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"On balance of probabilities, Mrs Dye would have survived but for the loss of electrical power," Mr Smith said.
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"No clear cause of that loss of power was identified," he said, adding that "a fault within the circuitry was suspected but not established to the required standard".
The report also warns that the investigation revealed electrical systems in the hospital may still be cause for concern. "In my opinion there is a risk that future deaths could occur unless action is taken," Mr Smith said.
"All staff at the scene were unaware of the cause of the loss of power, never having experienced such a situation previously, and an engineer was summoned to attend to reinstate the power, which he did."
Despite this, the report found evidence for similar such outages nationally. "It is plainly something which can, and does, occur."
"Had staff been aware of the exact cause of the loss of power on this occasion and had they had the opportunity to reset the circuit without the need to await the arrival of an engineer, who in turn had to attend a separate plant room, the downtime would likely have been significantly reduced."
Mr Smith added: "There may well be future cases within which such fine margins are time critical."
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The report states that NHS England has a duty to respond to the issues raised in the report by 28 August 2025.
An NHS spokesperson told The Independent: “NHS England extends its deepest sympathies to the family and friends of Jean Dye. We are carefully considering the Prevention of Future Deaths Report sent to us by HM Coroner and will respond in due course.”