Inquests put on hold after coroner raises concerns over doc’s reports
EXPERT SAYS FINAL CAUSE OF DEATH WAS INCORRECT IN MOST OF THE 38 POST-MORTEMS REVIEWED
A STRING of inquests have been put on hold after a coroner ordered an expert opinion into a senior Manchester doctor carrying out post-mortems.
Concerns were raised about Dr Khalid Ahmed’s work around 18 months ago by North Manchester coroner Joanne Kearsley.
She then commissioned a review of a sample of his post-mortems, which found his reports to be ‘inadequate’ and that most of them had given an ‘incorrect’ cause of death.
Until earlier this year Dr Ahmed worked as a consultant histopathologist for Pennine Acute NHS Trust, a senior medical role in which he helped to diagnose patients.
At the same time he also performed post-mortems for the North Manchester coroner’s office, which covers a similar area to Pennine.
Once concerns were raised in 2017, Pennine Acute began auditing the quality of his NHS work, while Professor Simon Kim Suvarna, a consultant histopathologist at Sheffield Teaching Hospitals, was called in to look into a sample of Dr Ahmed’s autopsies for the coroner.
Prof Suvarna’s resulting review of 38 post-mortems reels off a range of scathing criticisms, including ‘multiple and significant deficiencies with Dr Ahmed’s reports that exist at many levels.’
It concluded that ‘the final cause of death in most cases reviewed was incorrect.’
A number of inquests in which Dr Ahmed’s post-mortem conclusions would have been key have now been delayed ahead of a hearing in September, when Ms Kearsley will determine whether all those cases that remain should form the basis of a public inquiry.
Prof Suvarna’s report, passed to the M.E.N. by a family whose inquest had been delayed, does not represent a final conclusion or coroner’s decision on Dr Ahmed’s work, but is likely to form part of that September hearing.
The report says: “Starting with the external examinations, it would appear that Dr Ahmed has not confirmed the patient’s identity, which is a major professional deficiency. Such identification is standard practice across the United Kingdom.”
Prof Suvarna goes on to note that – assuming Dr Ahmed was examining the correct bodies – a ‘range of deficiencies’ had been identified in his conclusions.
That included the labelling in his pathology reports of tissues and organs that had already been removed from the body in question, alongside the failure to ‘identify and appreciate the significance’ of key bodily changes such as gangrene and ‘minimal’ commentary on bodily areas that had previously been operated upon for cancer, meaning any potential recurrence of the disease could go unconsidered. It found ‘errors and deficiencies’ in Dr Ahmed’s internal tissue examinations, including that he used ‘standardised descriptions’ of the cardiovascular system ‘such that almost all his cases have the same acute and previous myocardial infarction – which is not borne out by the clinical history or subsequent histology.’ Prof Suvarna’s report also notes the ‘final summary text’ is missing from most cases he reviewed, while adding: “Dr Ahmed produced pathology reports in a manner whereby one may even have concerns that the wrong slides have been considered.” In one case a patient’s toxicology results had been ‘over-interpreted,’ leading to the wrong cause of death, says the review, while adding that his reports lacked the kind of commentary needed by ‘clinicians, nursing
Dr Ahmed’s reports are inadequate and do not even meet the standards that are expected for pathology students Prof Suvarna’s report
staff and society as a whole.’ “The overall failure to correctly interpret macroscopic, histological and other data has meant that the final cause of death in most cases reviewed was incorrect,” it concludes. “Dr Ahmed’s reports are inadequate and do not even meet the standards that are expected for pathology students to pass the autopsy component of the final exam.
“It is clear the cases reviewed are but a fraction of Dr Ahmed’s work, which go back over many years.
“I have significant doubts with regard to the validity of all of this man’s reports while he was working as a consultant in Manchester.”
It is not clear how many postmortems Dr Ahmed has carried out for coroners’ departments in Greater Manchester, or for how long. Pennine Acute said that while concerns relating to Dr Ahmed’s coronial work had been identified, internal investigations into his NHS work for the trust’s hospitals had not revealed significant irregularities.
A spokesman said: “The trust first became aware of concerns raised about Dr Ahmed and his private coronial post-mortem practice following communication from Her Majesty’s Coroner in May 2017,” it said.
“We immediately commenced an in-depth internal review into Dr Ahmed’s practice in totality, which concluded in February 2018.
“This investigation covered the full extent of Dr Ahmed’s clinical practice as trust governance mechanisms had also highlighted concerns regarding his NHS work for the organisation.
“These were already the subject of internal inquiry. A thorough and extensive investigation in relation to Dr Ahmed’s NHS work was completed. This has provided assurance Dr Ahmed’s general histopathology practice is within the range of a reasonable pathologist.
“The coronial post-mortem reports, where concerns were raised with the trust, were reviewed by external independent expert pathologists instructed by the trust and the coroner’s office.
“The findings of these reviews revealed significant concerns in respect of Dr Ahmed’s coronial postmortem practice. This evidence was collated and was shared with Her Majesty’s Coroner’s Office and the appropriate professional bodies, including the General Medical Council. Further investigations are now being undertaken by Her Majesty’s Coroner’s Service and the trust is providing full assistance.
“The well-being of patients and bereaved relatives remains the trust and the coroner’s office priority and we apologise unreservedly for any stress this may cause.”
Pennine also confirmed that Dr Ahmed had also been training lead for general pathology at the trust between 2012 and 2014. He had been responsible for ‘monitoring and ensuring staff were compliant with mandatory training,’ it said, as well as providing ‘general educational training and supervision’ to doctors in their second and third years of training ‘during their supervised introduction to post- mortem work.’
“Doctors in training are trained and supervised by a wide range of doctors, over many years, at many different NHS Trusts,” added the trust. “There are no known concerns regarding Dr Ahmed’s educational knowledge or his training practice at The Pennine Acute Hospitals NHS Trust.”
It is understood Dr Ahmed no longer works for Pennine Acute.
North Manchester’s coroner has not commented.
Dr Ahmed, through his lawyers, declined to comment.