AN ELDERLY woman died on an operating table as surgeons attempted a pioneering operation to save her life.

A verdict of misadventure was recorded on 78-year-old Esme Stubbs, who died in Royal Bournemouth Hospital in November 2002 at the end of a heart operation.

A Bournemouth inquest heard surgeons at Southampton General Hospital had refused to operate on the mother-of-eight from Shipton Bellinger, Hampshire.

Mrs Stubbs, who was suffering from an aortic tear, would have died within hours without surgery.

Doctors attempted to solve the problem with a device called a stent-graft. The stent-graft was a type they had not used before and they were given a "dry run" by the manufacturer's UK managing director.

Two and a half hours into the operation, the device ended up in the wrong position and damaged an artery. Mrs Stubbs was pronounced dead after four hours in surgery.

Peter Taylor, a consultant vascular surgeon at Guy's Hospital, told the inquest: "They were terribly unlucky. Five millimetres the other way, they would have been heroes."

The stent had to be inserted through a tube running from the patient's groin to her heart. But a diseased artery made the operation more difficult.

Consultant interven-tional radiologist Dr David Shepherd, who was part of the operating team, said Southampton's thoracic team had turned Mrs Stubbs down for an operation because "they didn't have the experience and I believe at that time they didn't have a budget for it".

Consultant vascular surgeon Simon Parvin, who inserted the stent, said: "It was extremely fraught.

"It was not straightforward. This was not an easy case."

Johannes Radvan, consultant cardiologist, had told Mrs Stubbs there was an 85 per cent chance of success. He agreed he may have been "over-optimistic" in interpreting the data available.

But he said Mrs Stubbs was "very brave" and knew her only hope lay in an operation.

East Dorset coroner Sheriff Payne said: "I think it would be entirely wrong if we were to regard medicine as an exact science. It's not.

"It's still necessary for doctors and surgeons to exercise judgement, often at short notice, in extremely difficult circumstances and try to do the optimum they can in certain circumstances.

"I believe that this team attempted to do the utmost that they could for this lady on an emergency basis and their attempt failed."