Friday, February 17, 2012
A fatal accident inquiry concluded three patients who underwent keyhole surgery to remove their gall bladders died as a result of mistakes during, and after, the operations. Agnes Nicol, George Johnstone, and Andrew Ritchie died within a three-month period in 2006 whilst in the care of NHS Lanarkshire in Scotland.
Later expanded to look at all three deaths, the inquiry initially established to look into the case of Nicol, 50, who received surgery in late 2005. A surgeon at Wishaw General Hospital mistakenly cut her bile duct and her right hepatic artery. Whilst suturing her portal vein, her liver was left with 20% of its normal blood supply; the errors were not discovered until her transfer to liver specialists at Edinburgh’s Royal Infirmary.
By then, her liver was seriously damaged. She developed septicaemia, dying from multiple organ failure in March 2006.
Johnstone, 54, underwent the same procedure at Monklands District General Hospital on May 9, 2006. A consultant surgeon accidentally damaged, possibly severing, his bile duct. He died two days later in intensive care from the combined effects of multiple organ failure and a heart ailment.
Ritchie, 62, died in intensive care a week after an operation in June 2006. He died from intra abdominal haemorrhage caused by errors during the surgery.
Different surgeons were involved each time and the inquiry, under Sheriff Robert Dickson, found no evidence of poor training or inadequate experience. Dickson noted that in each case there was lack of action on a “growing body of evidence that there was something fundamentally wrong with the patient” and surgeons failed to contemplate their own actions as potentially responsible. He agreed with two professors that it may have been possible to save their lives “had the post-operative care been to the standard which they expected, and had there been a proper management plan which staff could have worked to” and noted that all the patients suffered from a lack of adequate medical notes being available after their surgery. He described the care as having “clear faults”.
NHS Lanarkshire has issued an apology, saying they “did fall below the high standards of care we aim to maintain in these cases and this has been extremely distressing for the patients’ families. We would like to take this opportunity to apologise to them.” The health board added improvements had been made regarding “these types of cases” as well as with document management.