Alice Jan Farrow, 83, from Hillcrest Avenue in Dereham, died at the Norfolk and Norwich University Hospital on June 7, 2025, after developing sepsis and multi-organ failure.

It came after a hole was torn in her oesophagus during a procedure at the hospital, an injury which occurs in fewer than 1 in 5,000 cases.

Norfolk coroner Johanna Thompson heard the perforation occurred during an attempted trans-oesophageal echocardiogram (TOE) - a specialist scan carried out by passing a probe down the throat to obtain detailed images of the heart.

Alive Farrow died at the Norfolk and Norwich University Hospital (Image: Supplied)

The test had been recommended after Mrs Farrow was diagnosed with worsening heart failure and severe mitral valve regurgitation.

Doctors hoped the results would determine whether she was suitable for less invasive treatment at Royal Papworth Hospital to ease her symptoms.

Her family said she had been keen to proceed in the hope it would allow her to remain independent.

“We were honoured to call this beautiful lady our mum and best friend,” daughters Natasha Ayre and Maria Dagless and son Matthew Dagless said in a joint statement read to the court.

“She was vibrant, kind and warm and had high hopes that this procedure would help her continue living the life she loved. She was not ready to go.”

The inquest heard Mrs Farrow had been admitted for the planned outpatient test on May 23.

Her daughter took a photograph of them smiling together after arriving by car, an image she said captured her mother hours before everything changed.

Consultant cardiologist Dr Cairistine Grahame-Clarke said difficulties were encountered almost immediately as the probe was introduced.

“There was an obstruction when we attempted to pass the probe,” she told the hearing.

“We gave further sedation and tried again with a different position but again met resistance. We decided to abandon the procedure because we were concerned about causing injury if we continued.”

Mrs Farrow was taken to recovery and later discharged after reporting a sore throat and some difficulty swallowing soft food. She was able to drink fluids and said she wished to return home.

However, just hours later she developed severe chest pain and was readmitted by ambulance.

A CT scan confirmed her oesophagus had been perforated during the abandoned procedure - a complication the court heard occurs in fewer than one in 5,000 cases.

Alice Farrow suffered a perforated oesophagus (Image: Supplied)

Alice Farrow died after a rare complication during outpatient surgery (Image: Supplied)

Dr Grahame-Clarke said surgery was not considered safe due to her frailty and underlying heart and kidney disease, so she was treated with antibiotics, fluids and pain relief in an attempt to prevent infection and allow the tear to heal.

“Initially she responded well and rallied, and I thought she would survive,” she said.

“I am very sorry for the events that occurred. This is a deeply regrettable incident and I have spent a great deal of time reflecting on my practice."

Despite treatment, Mrs Farrow’s condition deteriorated over the following days. Infection developed and her heart and kidney function worsened, leading to multi-organ failure.

Her family described how she had previously lived independently with minimal support, walking her dachshund Pippa each day and cooking for neighbours and relatives.

“Our little nanny lost her husband in July 2024 but she was not ready to join him,” her grandchildren said in a tribute.

“She still had so much life left and wanted to be here for all of us and for Pippa.”

They told the inquest the period following the aborted procedure marked a dramatic turning point.

“That operation was the day we lost her,” they said.

“She deteriorated rapidly after the hole in her oesophagus.”

The family also raised concerns about communication during her final admission.

“We did not feel fully informed about what was happening or the risks she faced,” they said.

“We were told different things about whether it was her heart, kidneys or the perforation that was causing her decline.”

However, they praised the care shown by frontline staff.

“The support on the ward cannot be faulted. From learners to nurses we will always be grateful,” they said.

A hospital safety investigation found Mrs Farrow had not been specifically advised of the rare but serious risk of oesophageal injury during the consent process or received written information.

Alice Farrow was 'never the same' after the operation (Image: Supplied)

The cardiology department has since updated consent forms and patient literature, and reviewed pre-procedure safety checks, including better identification of swallowing difficulties and clearer discharge advice.

Giving her conclusion, Ms Thompson said Mrs Farrow died from sepsis caused by oesophageal perforation during the procedure, with heart valve disease and kidney failure contributing.

“This was an extremely rare but recognised complication of a procedure recommended to assist in the management of her serious cardiac condition,” she said.

Recording a conclusion of accidental death, the coroner noted that improvements had since been implemented locally and she did not consider it necessary to issue a prevention of future deaths report.

Mrs Farrow's family said they hoped telling her story would help ensure lessons continue to be learned.

“We would hate for another family to go through what has been a horrendous journey,” they said.

“Nobody intended to harm mum, but that does not mean things could not and should not have been different.”

© Eastern Daily Press