Wishaw General Hospital
LANARKSHIRE health chiefs have apologised to the families of patients who died from complications following treatment at Wishaw General Hospital.
Motherwell man Andrew Ritchie (62), and Agnes Nicol (50), of Carluke, died in 2006 after developing complications following surgery to remove their gall bladders.
The sheriff conducting a fatal accident inquiry (FAI) reported last week that Mr Ritchie had suffered a number of health problems, but none were life-threatening – while mistakes in Mrs Nicol’s treatment at Wishaw General were not discovered until she was transferred to the liver unit at Edinburgh Royal Infirmary.
A spokesperson for NHS Lanarkshire said: “We have just received the determination and will take time to consider the sheriff’s comments.
“We 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 FAI into the deaths was held after it emerged three deaths (the other involved Airdrie man George Johnstone) had occurred in a three-month period in 2006 following a keyhole gall bladder removal (or endoscopic chlolecystectomy) in a Lanarkshire hospital. This is one of the most common operations carried out and there was concern that on three separate occasions patients died following such an operation.
Mrs Nicol died in Edinburgh Royal Infirmary on March 10, 2006. The cause of death was “multiple organ failure due to recurrent septicaemia due to hepatic infarction due to complications of endoscopic chlolecystectomy” carried out on December 22 at Wishaw General Hospital.
The complications were caused by a mis-identification of the anatomy by a staff grade surgeon who wrongly cut the common bile duct and right hepatic artery and the subsequent suturing of the portal vein by a consultant surgeon cutting off 80 per cent of the blood supply to the liver. These mistakes were not discovered until Mrs Nicol was transferred to the liver unit at Edinburgh Royal Infirmary.
No attempt was made at Wishaw General Hospital to investigate why her condition was deteriorating and “the consultant did not record anything in the medical notes”. He ignored exceptionally high figures which showed a major liver problem until December 28. By the time Mrs Nicol was sent to Edinburgh, her liver was so badly damaged that she died there.
Mr Ritchie died in the intensive care unit at Wishaw General Hospital on June 23, 2006. The cause of death was an “intra-abdominal haemorrhage due to dehiscence of the duodenal surgical site due to a laproscopic cholecystectomy due to chronic cholecystitis.”
The duodenal perforations occurred during or as a direct result of surgery carried out by a consultant general surgeon on June 14. No investigation took place until June 20 to ascertain why there was a continuous discharge of bile. Despite the consultant recording the possibility of a duodenal perforation on June 16, no scan or operation followed.
The inquiry found that there were individual circumstances in relation to each of the deaths and errors made in surgery and in particular the post-operative care of the patients which caused those deaths. They involved different consultant surgeons and there is no evidence that there was a lack of training or experience in the surgeons involved.
Although the evidence established that the circumstances of each death was different, and the complication which arose in the course of the surgery which led to the patient’s death was different in each case, there were certain factors which are common to at least two if not all of the deaths which require to be commented on.
l The failure to ensure the filing of all reports within the hospital records.
l The rota system which existed in 2005 (but which has been subsequently changed) whereby a patient admitted as an emergency becomes the responsibility of the consultant on duty on the day of admission. This was despite the fact that there could be other consultants within the hospital staff who had a greater expertise or experience in the relevant field of surgery.
l The policy which existed in 2005 that a patient displaying major gall bladder problems on initial admission to the hospital would almost invariably be treated conservatively and expected to return at a later date for an elective operation.
l The failure of the surgeons to consider the possibility that there had been a misidentification of the structures or that structures had been damaged in the course of the operation. This was the cause, or was significantly contributory, to each patient’s failure to recover.
l The evidence before the inquiry showed that at the time the lack of a complete set of records and documents in relation to any of the three patients was indicative of a system which requires to be overhauled.
Sheriff Robert Dickson said: “It is essential that every doctor and nurse responsible for the care of a patient has access to all the records and all the documents and that full notes are available at all times.
“In relation to the care of Mrs Nicol, Mr Johnstone and Mr Ritchie, this was not so and I can only hope that NHS Lanarkshire will ensure in future that firstly there is full documentation recorded by both the doctors and nurses involved in each stage of the treatment of patients, and secondly that the records department ensures that all the hospital records are kept and made available to all those who require access to them.”
The spokesperson for NHS Lanarkshire added: “We have made significant improvements to the management of these types of cases and have also made significant changes to documentation and the way in which case notes are managed. However, we will study the determination in detail to identify if there are any further areas where we can improve to ensure that similar mistakes do not happen again.”