A WOMAN died in hospital in "one in a thousand" circumstances, an inquest heard.

A consultant with 20 years' experience failed to find a vein in her chest and "nicked" her lungs, causing her to have a heart attack, the York inquest was told.

Consultant Morris Pye said he had carried out 1,000 pacemaker operations and it was the first time this had happened.

Widow Edith Sayner, 78, of Viking Close, Riccall, died on February 16 last year in York Hospital - two days after the operation.

The inquest heard that when Mr Pye tried to fit the pacemaker he could not find the right vein.

Mr Pye said it was a normal procedure, but was difficult because of the anatomy of the patient. He tried several times and eventually had to ask a colleague to help.

A later chest X-ray revealed the lungs had been "nicked" during surgery, and air had entered the chest cavity.

Registrar Joanne Ridpath said the next morning Mrs Sayner was more breathless.

A further chest x-ray showed blood had entered the chest cavity, and she drained 400 millilitres of fluid.

Mrs Sayner's son, Graham, asked if Dr Ridpath would confirm that she told him she would be carrying out another drain at 5pm.

Dr Ridpath said: "What I meant was if there was a need to do it, there would be another drain."

Mr Sayner said: "I have a great concern that what you are saying is not what you said to me on the day. It is contrary."

Another drain was eventually carried out at 10pm, an hour after Dr Ridpath left the hospital, removing 700 millilitres of fluid.

But at midnight Mrs Sayner had a heart attack, and died at 12.40am.

Mr Pye said in the thousand pacemaker operations he had carried out he had never seen a patient suffer such grave consequences.

York coroner Donald Coverdale said he was sure the operation and aftercare was carried out in good faith and there were no "slip-ups".

He said Mrs Sayner, who suffered from heart disease, died from bleeding caused by the operation.

He recorded a verdict of death by misadventure.

Mr Sayner said afterwards that he would be seeking legal advice about the aftercare his mother received and about his unhappiness with the evidence given.

A spokeswoman for York Hospitals Trust said there were other concerns expressed by Mrs Sayner's family, which could not be handled at the inquest.

She said: "We hope to be able to discuss these concerns further with them and provide some answers to any outstanding issues."

Updated: 15:21 Wednesday, June 16, 2004