A coroner calls for action from a hospital after four patients have died in six months from complications from the same gallstone procedure.
Carol Cole, 53, William Doleman, 76, Anita Burkey, 85, and Peter Sellars, 72, died after undergoing endoscopic retrograde cholangiopancreatography (ERCP).
Coroner Laurinda Bower said following a 15-day inquest that it was the systems in place in Nottingham that led to their deaths rather than the technical skill of a trainee doctor who performed all four surgeries.
Bower is set to release a report on preventing future deaths demanding action from the Nottingham University Hospitals NHS Trust over concerns that the four patients were not properly informed of the risks of the procedure.
The coroner found that Ms Cole, Mr Doleman, Ms Burkey and Mr Sellars died of complications following ERCP – a procedure whereby a tube is passed down a patient’s throat to examine and remove. possible gallstones of the common bile duct.
Carol Cole, 53, was one of four patients who died after undergoing an endoscopic retrograde cholangiopancreatography (ERCP) procedure
Anita Burkey, 85, died after undergoing endoscopic retrograde cholangiopancreatography (ERCP) procedure
All four patients were treated by trainee physician Muthuram Rajaram, but Bower concluded that these were the âsystems in placeâ to properly obtain consent and educate patients about the risks of the procedure that were involved, not the system. technical competence of Dr Rajaram.
The Nottingham University Hospitals NHS Trust now has 56 days to create an action plan after receiving the coroner’s report on preventing future deaths, reports the BBC.
Concluding the inquest, the coroner said: âThese cases rightly gave rise to concern when it was identified that all four deaths had occurred at the hands of the same intern and within the span of about six. month.
“But as the evidence crystallized over the course of the investigation, the problems appear to be more with the systems in place in Nottingham than with Dr Rajaram’s technical competence.”
The coroner found that William Doleman, 76 (left) and Peter Sellars, 72 (right) also died of complications from ERCP.
The investigation learned that Mr. Doleman should not have undergone the ERCP, Mr. Sellars and Ms. Cole were not made aware of the individual risks, while Ms. Burkey was not sufficiently consulted.
Ms Cole, of Broxtowe, died of an aggressive form of pancreatitis at Queen’s Medical Center teaching hospital and her death was deemed “unnatural” by Bower.
The mother-of-two was diagnosed with gallstones last year after experiencing abdominal pain, which led to her undergoing ERCP.
But after returning home from the procedure, Ms Cole described feeling like her “insides were tearing apart” and said she was “in agony”.
She was rushed to hospital with pancreatitis and placed in intensive care, but later died.
Ms Cole, of Broxtowe, died of an aggressive form of pancreatitis at Queen’s Medical Center teaching hospital and her death was deemed “unnatural” by Bower
Trevor Cole, who has been married to his wife Carol for over 20 years, said: âOur whole family is devastated having to adjust to life without Carol.
âNone of us were prepared for this after the procedure was just a minor routine operation and I had no idea that she was so dangerously ill that night.
âI was in shock when I was told that Carol was gone and I don’t remember much after that other than having to break the news to our sons, Ashley and Mitchell. It was one of the most difficult things I have ever had to do.
âShe was taken from us far too soon and will be missed by all who knew her. For me she was perfect and I will never forget her.
The coroner, speaking to the families, said: âI can’t imagine how difficult it has been for all of you to have lost a loved one under these circumstances.
âI hope that over time you will derive some comfort from the fact that I certainly intend that some learning may come from these deaths, so that the safety of this high risk procedure continues to exist. ‘to improve, that understanding personal risk and discussing those risks with patients becomes a standard part of the journey, and that will be the legacy of Bill, Anita, Peter and Carol.’
Phillip McGough, of Freeths Solicitors, who represented the families of Mr Sellars, Ms Burkey and Mr Doleman, told the BBC: âOur customers were convinced that many things went wrong here to varying degrees and that there were many questions that needed to be answered.
‘[They’re] saddened because from what we’ve heard over the past three weeks in this coroner’s court, much of what happened was preventable.
“We can only hope that the lessons learned here will be applied by the Hospital Trust in the future.”
John Walsh, Deputy Medical Director of Nottingham University Hospitals NHS Trust, said: ‘We would like offer our sincere condolences to the families for their loss and we are truly sorry for the gaps in the care we have provided.
âWhile each case is unique, we should have done more to involve families in decisions about patient care as well as take other steps to manage these complex and high-risk cases.
âWe have made significant changes to a number of our trusted policies and processes in these areas, including a review and changes to when and how we report a serious incident, to ensure that patients undergoing serious ERCP procedure receive appropriate and timely care. they need.’