Deaths that forced changes at city hospitals
CORONER’S VERDICT SPARKS TRUST’S NEW PROCEDURES
NOTTINGHAM hospitals are making big changes after four patients died in six months after a high-risk but routine medical procedure.
Nottingham University Hospitals NHS Trust turned the spotlight on itself after the deaths of two men and two women.
William Doleman, 76, Anita Burkey, 85, Peter Sellars, 72, and Carol Cole, 53, died after a tube was passed through their throats to examine and treat possible gallstones and other conditions.
The operations were all carried out by the same doctor – gastroenterologist Muthuram Rajaram – but a coroner concluded that systems to gain consent and inform patients of the risks of the procedures were the issue, not the doctor’s competence.
Now there is a policy of keeping patients who have undergone an endoscopic retrograde cholangiopancreatography (ERCP) procedure for a minimum of two hours before discharge, to improve monitoring.
More consultants have been appointed who can conduct alternative, lower-risk endoscopy (EUS) to ensure that ERCP endoscopy is still required if there has been a delay in attending for the procedure.
A “Consent and Candour Group” – chaired by the trust’s deputy medical director – has also been set up to ensure that potential complications are identified and communicated to patients, and their families as appropriate.
The four cases in question were considered so serious that Laurinda Bower, assistant coroner for Nottingham and Nottinghamshire, issued a prevention of future deaths report after hearing evidence over 15 days.
The trust is required to write to her telling her what it plans to do within 56 days.
At a hearing on December 17, she concluded: “I have a duty to issue a report on action to prevent future deaths where I have a concern that circumstances creating a risk of other deaths will occur, or will continue to exist, in the future, and in my opinion action should be taken to prevent this occurrence.
“The report on action must be sent to any person who I believe may have power to take such action.”
After the hearing, John Walsh, deputy medical director at NUH, said: “We would like to offer our sincerest condolences to the families for their loss and we are truly sorry for any shortcomings in the care we provided.
“Although each case is unique, we should have done more to involve families in decisions about patient care as well as taken other actions to manage these complex, high-risk cases.
“We have made significant changes to a number of our trust policies and processes in these areas, including a review of, and changes to, when and how we declare a serious incident, to ensure that patients undergoing an ERCP procedure receive the appropriate and timely care they need.”
After the inquest, Phillip Mcgough, of Freeths Solicitors in Nottingham, representing the Burkey, Doleman, and Sellars families, said: “The Burkey, Doleman, and Sellars families were both pleased and saddened by the outcome of the inquest.
“Pleased in as much as their concerns about things going badly wrong here – both in terms of the actions of
the individual clinicians involved, and the defective systems in place behind them – have been vindicated.
“Saddened, because so much of what happened was avoidable.
“Questions have been answered, but this is small comfort for my clients, especially at this time of year when the absence of their loved ones is felt all the more acutely.
“We can only hope that the hospital trust applies the lessons learned at the inquest, so that no other families have to experience this kind of tragedy.”
William Doleman was 76 when he died at the Queen’s Medical Centre on April 1, 2020.
It was likely that he had a perforation towards the end of the procedure.
Miss Bower said: “At the time, this procedure was not clinically indicated, and ought not to have gone ahead.
“If the procedure had been postponed for further imaging, Bill would not likely have died when he did and in the manner that he did.
“Failures in his pre-procedure care directly contributed to his death.
“There were missed opportunities to have diagnosed and treated Bill’s perforation during the procedure, and while this would have likely reduced his risk of dying, it might not have prevented his death.”
Anita Burkey was 85 when she died on April 5, 2020, at City Hospital, as a result of complications after her ERCP when there was a perforation.
Miss Bower said: “This procedure should never have been performed on this date and in the circumstances as it was unsafe to do so when Anita’s capacity and consent had not been appropriately assessed, and her history of dysphagia [difficulty or discomfort in swallowing] had not been explored.
“Anita died as a direct result of the procedure which was performed as a result of significant failings in her care.”
Peter Sellars, 72, died at the QMC as a result of a complications of pancreatitis after the procedure.
In his case, Miss Bower found: “I find that Peter died as a result of complications of a procedure that was both necessary and appropriately performed.”
Married mother-of-two Carol Cole, 55, who worked for the trust at City Hospital, died at the QMC of an aggressive form of pancreatitis which was probably triggered by the ERCP.
After arriving home, Carol started to feel unwell and, by 8.20pm, was in a lot of pain, describing it as feeling like her “insides were ripping”. She said she was “in agony”.
After the inquest, her husband, Trevor Cole, of Broxtowe, said: “It’s taken a long time to get to this point due to Covid-19, but now we have a conclusion and some answers, I’m hopeful that we can move forward.
“I can only imagine what it might have been like for Carol in agony with no-one to comfort her and reassure her that everything was going to be OK that night when she was in hospital.
“No-one could have known at the time that it was going to end like this but I do feel that Carol was let down at the time she needed help the most. “I hope that NUH learn from this and put in place fail safes to prevent future deaths, so that the four individuals at the heart of this inquest won’t have died in vain.
“My thoughts are with the other families at this time as well.”
During the inquest, Miss Bower told the families: “I hope that in time, you draw some comfort from the fact that it is certainly my intention that some learning can come from these deaths such that the safety of this high-risk procedure continues to improve, that the understanding of personal risk and discussion of those risks with patients becomes a standard part of the pathway, and that shall be the legacy of Bill, Anita, Peter and Carol.”
I can only imagine what it might have been like for Carol in agony with no-one to comfort her Trevor Cole