WHEN her mother died suddenly in hospital under unusual circumstances, Christine McKenzie wanted to know why. 

Six years on, the retired advertising executive said investigations into the tragedy have only added to her grief and left her "with more questions than answers" after the Crown Office and Ombudsman found no faults with her care, despite a damning post-mortem.

Mrs McKenzie, an only child, was devastated when her 84-year-old mother, Mabel Campbell, died from a "one in 100,000" internal bleed hours after undergoing a biopsy.

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Mrs Campbell suffered a fatal gastro-intestinal haemorrhage at the Victoria Infirmary in Glasgow on September 4 2012, 12 days after she was admitted with shingles and renal failure.

The death automatically triggered a Crown Office probe because it had occurred within 24 hours of surgery.

Pathologist Dr John Clark said the cause of death was bleeding from biopsy sites in the small intestine, where tissue samples had been collected during an endoscopy on September 3.

In his post-mortem, Dr Clark stressed "all the inflammation and haemorrhage seen at the biopsy sites occurred following the procedure".

In its report, the Crown Office stated that "according to Dr Clark, Mrs Campbell would not have died when she did had the biopsies not been carried out".

The case was subsequently referred to Dr John Dillon, a consultant gastroenterologist at NHS Tayside, for a second opinion.

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Although he stressed that he believed the care provided to Mrs Campbell "was of a good standard throughout her admission", he added that bleeding from endoscopic biopsies is "exceedingly rare" and that he had encountered only one such case in 17 years.

He noted, however, that Mrs Campbell was on aspirin and enoxaparin to thin her blood and these drugs "would have greatly reduced her chances of normal clotting post-biopsy".

He added that it "would be standard practice not to biopsy patients who are [on blood-thinning medication]".

Within hours of the procedure Mrs Campbell had coughed up some blood and the following day an "obvious GI bleed was declared" after she began vomiting up blood and passing blood in her stools. Efforts to resuscitate her failed.

Mrs McKenzie, 66, said she was dismayed when the Crown Office ruled out a Fatal Accident Inquiry into her mother's death in May 2014, saying their investigation "did not identify any systemic failures that caused or contributed to" the fatality.

She was especially distressed by contradictory accounts from ward staff that Mrs Campbell's blood-thinning drugs had been stopped prior to the biopsy, despite there being no record of this in her paper medical and nursing notes.

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In its report, the Crown Office said that a staff nurse explained that a number '14' noted in the hospital's Kardex computer system for Mrs Campbell on September 4 and 5 2012 indicated that a drug has been withheld.

However, a second ward nurse told the Crown Office that she had withheld enoxaparin on September 2 and 3 and would "normally have documented that the drug was withheld but did not on this occasion".

The consultant in charge of Mrs Campbell told the Crown Office there was "no requirement for for nursing staff to record discontinued drugs", but insisted the anticoagulants were stopped in time so that the biopsies "could not have contributed to any bleeding that occurred".

The Crown Office noted Dr Dillion's estimate that bleeds from endoscopic biopsies occur in around one in 100,000 cases, and concluded "so these events would be expected to occur".

Mrs McKenzie, who is originally from Glasgow but now lives with her husband, Jim, near Salisbury in England, said: "There are so many contradictions between the post-mortem and Dr Dillon's report and what the hospital say happened.

"I still don't know why my mother died. I just feel so let down."

Her husband, Jim McKenzie, added: "The consultant said the nurses 'don't have to tell them' prior to a biopsy what drugs have been cancelled. I think that's a bit worrying.

"There should have been a clear checklist, stating what drugs she's on, which have been stopped, and when they were stopped. There isn't."

As the investigation dragged on, Mrs McKenzie said repeated requests to speak to members of the Crown Office team went unanswered and she was wrongly told not to make a complaint to the health board until the Crown Office probe had concluded - by which point it had exceed the 12 month time-bar.

In light of the error, the Scottish Public Services Ombudsman (SPSO) agreed to take on the case, but Mrs McKenzie was disappointed again with the outcome.

Although it criticised as a "serious omission in record-keeping" that there was no Standard Early Warning System (SEWS) chart in place for Mrs Campbell after her endoscopy on September 3, when she required more frequent and closer observation, overall the watchdog concluded Mrs Campbell's endoscopy was "carried out appropriately and to a reasonable standard".

Mrs McKenzie said her attempts to speak to someone at the SPSO by telephone about the case have been rebuffed, adding to her distress.

Rosemary Agnew, who heads the SPSO, said she could not comment on specific cases, but stressed they took complaints about the service "very seriously". 

She said: "Naturally, we were sorry to hear about the complainant's concerns about our service as we strive to deliver excellent customer care."

An NHS Greater Glasgow and Clyde spokeswoman said: “The SPSO concluded that the care this patient received was appropriate but NHSGGC could have handled the family’s complaint more appropriately. For this we have already apologised in writing to the family.”

A Crown Office spokesman said: “After careful consideration of the facts and circumstances of the death of Mabel Campbell Crown Counsel concluded that there were no systemic failures that caused or contributed to the death and as such there was no basis to hold a FAI."

In relation to the delay which meant Mrs McKenzie was too late to lodge a formal complaint with NHSGGC, the spokesman added: "It is not the role of the Crown to provide guidance or advice to the nearest relatives of the deceased on civil matters or the complaints policies of other organisations.”