Expert: Missed opportunity to learn lessons
A consultant examined an internal NHS Lothian report on behalf of the family before voicing deep concern that a full post mortem had not been carried out and said an opportunity to learn from the tragedy had been lost.
The respected specialist said:
“If ever a death warranted a post mortem, this certainly did as the first to list mesh as a cause.
“As a result, an opportunity to learn vital lessons which could prevent future deaths, was lost.
“The hospital appears to still be in denial about the role mesh played in this death. They need to admit it, and learn from it. If we cannot learn and reduce the risk to others, this mesh procedure should be stopped.”
The expert said the routine pathology work carried out fell far short of what would have been expected in a full post mortem.
The consultant said: “The pathology report states there was evidence that diverticulitis disease was worse where mesh was present. But unless this was compared to the rest of the colon, we learn nothing.”
Neil Findlay, Scottish Labour MSP for Lothian, is backing the family’s call for an FAI and immediate suspension of the mesh implant used on Eileen.
He said: “I find it incomprehensible why there was no full post mortem in this case despite Eileen’s death being the first in the UK to have mesh named on her death certificate as a contributory factor.
“Following NHS Lothian’s review of this case, Eileen’s family have been left with even more questions than answers and that is unacceptable.”
The consultant who reviewed the report noted there had been “significant delays” of up to eight months in the management of the prolapse mesh which had eroded into Eileen’s bladder and also affected the discovery of mesh attached to her bowel.
Inflammation and infection coupled with mesh erosion and bowel leakage led to overwhelming bacterial peritonitis and septicaemia. Eileen was rushed to hospital on August 19 last year and died eight days later.
With every passing year, every life ruined, and every billion paid out in compensation, one seems certain to become the world’s biggest health scandal. The other, according to a report released on Friday, is no scandal at all.
However, the disastrous mesh implants that have blighted the lives of more than 100,000 women around the world and the health fears at a high school campus in Coatbridge have one thing in common.
The abject failure by North Lanarkshire Council and NHS Lanarkshire to engage with worried parents, teachers and pupils, listen to their concerns and work in good faith to effectively address them, will be no surprise to the mesh-damaged women of Scotland.
For too long, they have endured the same official arrogance, intransigence and inaction. When our chief reporter Marion Scott first exposed the life-changing injuries suffered by mesh-damaged Scots women in 2013, the sheer scale of the suffering that would emerge in the months and years to come was unimaginable.
It was certainly unimaginable for each of the victims, every one of them told by their doctors that their post-mesh suffering was exceptional and their health problems unique. A dismal litany of official reviews, committees and warm words then took the place of effective action. It is now hard to be
‘ Sclerotic culture of inaction and arrogance runs through Civic Scotland like a seam
surprised by the medical and political establishment’s silence and inaction but today, incredibly, we reveal how the first woman in Britain officially killed by mesh was not even given a post mortem.
That one decision, that single failure, sums up the sclerotic, see nothing-do nothing culture of official oversight that runs like a seam through much of civic Scotland.
For example, when we revealed the health fears of teachers, parents and pupils at the Coatbridge schools built on a toxic landfill sites, North Lanarkshire and NHS Lanarkshire insisted there was nothing to discuss and when comment was reluctantly dragged from them they offered only dismissive, blithe assurance that had no evidence to support it.
A few Pollyannas in the press were happy to take them at their word, without evidence or inquiry. Thankfully, however, most journalists continued to give a voice to those worried teachers, parents and pupils asking to see the evidence – the air, soil and water tests accumulated, year by year, since the school opened. Unhappily, for the council there did not seem to be any.
The report, compiled by Dr Margaret Hannah, the independent public health specialist, and released on Friday, was produced under deadline. If not rushed, it was certainly not as thorough as anyone would have liked but, still, she firmly believes the schools are safe.
Let us hope so but let us hope also that the authorities understand it was their own dereliction of duty, their own failure to listen, act and provide the evidence to prove their claims that exacerbated this crisis.
The awful, ongoing ordeal of Scotland’s mesh-damaged women, might suggest we will hope in vain.