NHS Lanarkshire criticised over three hospital deaths

One of the patients died at Monklands Hospital in Airdrie
One of the patients died at Monklands Hospital in Airdrie
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NHS Lanarkshire has apologised to the families of three people who died following operations in its hospitals.

The health board issued the apology after a Fatal Accident Inquiry (FAI) criticised levels of care, saying there were “clear faults” in the post-operative care of the three patients.

Sheriff Dickson said there was a “realistic possibility” that the deaths might have been avoided if the care had been of the expected standard.

The FAI was held in autumn 2011 after Agnes Nicol, George Johnstone and Andrew Ritchie died in a three-month period in 2006 following a laparoscopic cholecystectomy (keyhole gallbladder removal).

NHS Lanarkshire said: “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.

“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.”

Mrs Nicol, 50, from Carluke, South Lanarkshire, died on March 10 2006 of multiple organ failure following complications from endoscopic chlolecystectomy carried out on December 22 2005 in Wishaw general hospital.

They arose after a staff grade surgeon wrongly cut the common bile duct and right hepatic artery, and the subsequent suturing of the portal vein by a consultant surgeon cut off 80% of the blood supply to the liver.

The mistakes were not discovered until Mrs Nicol was transferred to the liver unit at Edinburgh Royal Infirmary, by which time the organ was so badly damaged that she died.

Mr Johnstone, 54, from Airdrie, North Lanarkshire, died in the intensive care unit at Monklands district general hospital, Airdrie, on May 11 2006.

The cause of death was multiple organ failure due to a biliary leak following laparoscopic cholecystectomy carried out on May 9 2006 within the hospital by a consultant general surgeon. A secondary cause of death was ischemic heart disease.

The leak arose due to the consultant either cutting or damaging the main bile duct.

Mr Ritchie, 62, from Motherwell, North Lanarkshire, died in the intensive care unit at Wishaw general hospital on June 23 2006 of an intra abdominal haemorrhage following a laproscopic cholecystectomy at the hospital on June 14.

In his determination published today, Sheriff Dickson said 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 the deaths.

He said they involved different consultant surgeons and there is no evidence that there was a lack of training or experience in the surgeons involved.

However, he highlighted common factors such as a lack of adequate notes in relation to the post-operative care of all three patients.

He wrote: “In relation to the management of the post-operation period, there were clear faults in the care of each of the patients.”

He added: “While it is not possible definitively to say that if each patient had been returned to surgery earlier, and if the necessary scans had been carried out timeously, that lives would have been saved, there is substance in the contention made by Professor Garden and Professor Kinsella (who both gave evidence to the FAI) that 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, that there remains a realistic possibility in each case that the death would not have occurred.”

He also said the consultants failed to consider the “growing body of evidence that there was something fundamentally wrong with the patient” and that the most likely cause was something which had arisen in the course of the operation.