Tracey Clarke described failures at every level in the care of her daughter Melissa, who died 10 days after undergoing heart surgery in October 1991.
The mistakes, omissions and lack of care described by Mrs Clarke, 36, from Devon, went far beyond the behaviour of the surgeons who were found guilty of serious professional misconduct by the General Medical Council (GMC) last year. She spoke of communication failures, faults in equipment, lack of support and a reluctance to confront problems which resulted in Melissa being kept on a ventilator for days after she was brain dead.
Mrs Clarke, who with her husband Graham is planning legal action against the infirmary, was the first of at least 500 witnesses due to give evidence to the inquiry, chaired by Ian Kennedy, professor of health law and ethics at University College, London.
Melissa was born with the main arteries to her heart transposed, causing her frequently to turn blue because too little oxygen was getting into her blood. She was operated on by Janardan Dhasmana, one of the three doctors found guilty by the GMC last year. Hospital records show that the operation went well. Mrs Clarke, who saw her daughter immediately after the surgery, said: "She looked lovely. She was pink and all the blue tinge had gone. I thought everything was fine."
It emerged yesterday, however, that 48 hours after the operation a problem occurred with the ventilator helping Melissa to breathe. A post-mortem examination report, which Mrs Clarke did not see until several years later, said Melissa had suffered respiratory failure "partially due to a mechanical failure in the ventilator". The report said it was "several hours" before "satisfactory oxygenation" was achieved. A second record referred to "split tubes" on the ventilator.
Mrs Clarke told the inquiry: "On the Thursday [nine days after the operation] I was not happy with what I was being told. I rang twice, the second time at 10.30pm, and I spoke to a doctor who said everything was going as planned. Those words are ingrained on my mind." Next morning she and her husband were called to the hospital. "We walked into the intensive care unit and all the nurses turned their backs on us."
After a three-hour wait, the couple saw Dr Stephen Bolsin, the consultant anaesthetist credited with blowing the whistle on the surgery failures. He admitted there was no hope for Melissa and that she was brain-stem dead.
The next day, the hospital told Mrs Clarke her daughter was still alive. She suggested it was time to switch off the ventilator. Half an hour later a nurse phoned to say Melissa had died in her arms.
The infirmary omitted to inform the Clarkes' local hospital in Exeter that Melissa had died and six months later the couple received a letter about a missed appointment. Last month, eight years after their daughter's death, they learned the infirmary had kept her heart for two months after the post-mortem examination.Reuse content