Gran died days after heart operation at Wolverhampton's New Cross Hospital

Inyat Begum, aged 71, was recovering after the operation at New Cross Hospital that replaced a valve in her heart and repaired the other. But six days later her family were told fluid had collected on her lungs and must be removed.

The procedure went tragically wrong when the tube inserted into Mrs Begum was positioned incorrectly and punctured her liver causing a fatal bleed.

Her daughter, Zabina Bi, said she was told there were no risks associated with having a chest drain by the doctor who carried it out, Dr Kamran Saleem, other than minor bleeding.

At an inquest, Black Country Coroner, Zafar Siddique, returned a narrative conclusion which recognised the wrongly inserted tube caused Mrs Begum's death but did not find there had been 'neglect.'

He added he would write to the chief executive of the trust which runs New Cross to see if they would consider changes to their policy on chest drains further to ones currently being introduced in light of Mrs Begum's death.

The inquest heard Mrs Begum, of Tividale Road, Oldbury, was diagnosed with heart failure in 2014 and had become increasingly unwell since January.

On June 25 she was admitted to New Cross Hospital and on June 28 the operation was performed by cardiothoracic surgeon, Dr John Billing. Mrs Begum had to be sedated following the operation but by July 3 was showing signs of improvement, the inquest heard. The following day her family were told she required the chest drain.

The inquest heard the tube was inserted 'too low' and cut into the liver causing Mrs Begum to lose 1.2 litres of blood which caused her death.

Since the incident the hospital trust has updated its policy making it mandatory for ultrasound scans to be carried out immediately before chest drain procedures." Jonathan Odum, medical director for the Trust, said afterwards: "We would like to express our sympathies to the family of Mrs Begum. Following her death an internal investigation was started. This is on-going."

In a family statement, her relative said: "We are devastated that we have lost our mum.

"From the inquest, we welcome the Coroner's recommendations to the trust on preventing future deaths as we do not want another family to go through a routine procedure with a catastrophic outcome.

"Our mother showed tremendous courage and fought so hard, she was the bravest person we have ever known.

"Our mother was the heart and soul of our family. She was married to our father for 50 years and was a loving wife and soul mate. She was a loving mother to eight children and a loving grandmother."