Studies have suggested that medical errors may be the third-leading cause of death in the United States, right behind heart disease and cancer.
For the past eight years in an effort to curb the number of preventable mistakes that happen in Indiana, hospitals, ambulatory surgery centers, abortion clinics and birthing centers have been required to report 28 serious adverse events to the Indiana State Department of Health.
In 2013, 111 medical errors occurred at 293 facilities, according to a report recently released by state health officials. That's more medical errors than have occurred in any year since the state started requiring facilities to report these events.
As in seven of the eight years that the report has been produced, serious bed sores lead this year's list of preventable medical errors, with 45 such incidents...
Bedsores
Once again, so-called pressure ulcers, acquired after a person is admitted, topped the list. An average of 32 stage three or four sores have occurred each year.
In 2013, 45 incidents of serious bedsores were reported, more than in any other year since the report was first published.
The elderly and others who are confined to bed because of illness are particularly prone to bedsores. So facilities are supposed to keep a watchful eye on their patients to ensure that small problems don't get out of hand and potentially lead to lethal infections.
Foreign objects
In some cases, surgeons are supposed to take things out of one's body. In others, they're supposed to put things in (think stents for clogged arteries). But on 27 occasions, surgeons in Indiana left a "foreign object" in a patient after surgery.
The Indiana State Department of Health does not require facilities to go into detail on their reports, so it's impossible to know exactly what those foreign objects were.
NoThing Left Behind, a national project to reduce the number of "retained surgical items" notes that common objects left behind include soft goods/sponges, needles, instruments and "miscellaneous small items."
Although one incident occurred in the previous year and was just reported now, the total is more than a 50 percent increase from the number of such events reported for 2012.
Wrong site surgeries
You've heard stories about doctors removing the wrong leg, operating on the opposite arm. Some patients have even taken to marking the right body part before they go under the knife.
Still, mistakes happen. On 13 occasions in the past year, an Indiana hospital performed surgery on the wrong body part, and in five cases, the fault was that of an ambulatory surgery center, for a total of 18 such incidents.
It should be noted that even if a surgeon stops before actually doing the full surgery, it counts under this category. So that could mean anything from a doctor numbing the wrong leg and then realizing his or her mistake before proceeding to actually operating on that leg.
In two other cases, the wrong surgical procedure was done.
Serious falls
It seems so mundane, but fall prevention is a critical piece of what hospitals must do to keep patients as healthy as possible. On 12 occasions, all in hospitals, a patient's fall resulted in either death or a serious disability.
Each year, an estimated 700,000 to 1 million patients fall in hospitals. Of these, as many as half result in an injury.
To encourage hospitals to work harder to prevent falls, the federal government in 2008 started refusing to pay for extra care necessitated by a fall while a patient was hospitalized.
This article is courtesy of indystar.com.
Regularly updated blog featuring news, articles and information relating to clinical/medical negligence.
Showing posts with label Wrong Site Surgery. Show all posts
Showing posts with label Wrong Site Surgery. Show all posts
Wednesday, 15 October 2014
Monday, 8 September 2014
Surgeon rendered patient infertile by giving him a vasectomy by mistake during minor operation
A surgeon has rendered a patient infertile by giving him a vasectomy when he went into hospital for a minor operation.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
The patient was the victim of what hospital chiefs have called a 'never event' - a medical mistake that should never happen.
The man, who had the original procedure at Broadgreen Hospital in Liverpool earlier this year, has been told that an operation to reverse the vasectomy was unsuccessful. He could now be entitled to more than £100,000 in compensation.
It is understood that the surgeon who performed the surgery has since been fired, according a report.
The urology department at Broadgreen Hospital, part of the Royal Liverpool and Broadgreen University Hospitals NHS Trust, has admitted the error was just one of five botched operations - and two 'never events' - in the last 12 months.
Another mistake involved a medical swab being left inside a patient during an operation.
The Royal Liverpool Hospital 'apologised unreservedly' to the man when details of the mistake, which they termed 'wrong site surgery', emerged earlier this year.
The vasectomy - and the failed reversal - means that the patient will not be able to conceive naturally.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said the vasectomy patient could be eligible for more than £100,000 in compensation, but it would depend on how old he is and whether or not he has been left infertile.
Mr Cohen said: 'This is a truly shocking and worrying case. From what we know there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'If a 25-year-old who wants a family is told he won’t be able to father children, it will be devastating.'
Hospital bosses say the blunders have been reported to NHS chiefs and that investigations are under way to establish how they happened.
Dr Peter Williams, medical director at Royal Liverpool and Broadgreen University Hospitals NHS Trust said: 'Our urology department is the biggest in Cheshire and Merseyside, caring for over 4,000 patients a year.
'The vast majority of feedback from these patients is overwhelmingly positive.
'We have excellent, highly regarded clinical teams who treat the most difficult urological cases, many of which are referred to us by other hospitals for our expertise and leading edge surgical techniques.
'In the last 12 months, three serious incidents and two never events occurred in our urology department and these were reported to the appropriate bodies.
'We are still in the process of investigating some of these incidents, including looking at how to improve the processes and systems in place and are taking appropriate action.
'We cannot comment on the outcomes of these investigations at this stage.
'Patient safety is always our priority and we use the lessons learnt from any incident to continually improve our standard of care.'
This article is courtesy of the Daily Mail.
Wednesday, 20 August 2014
Leeds hospital blunders revealed in report
Doctor wrongly removed a woman’s kidney after mistaking it for an ectopic pregnancy, a new report on serious incidents at Leeds hospitals shows.
Two patients also received adrenaline overdoses, there was an outbreak of MRSA among new mums and staff failed to respond when a patient deteriorated, according to the document.
It details 16 serious incidents recorded by Leeds Teaching Hospitals NHS Trust in May and June, with 11 of these pressure ulcers.
The report, by chief medical officer Dr Yvette Oade, says there has been an increase since 2013 in the number of serious incidents.
She said: “Whilst this reflects our reporting and learning culture, this is also attributable to a decision that we took to report all category 3 pressure ulcers as serious incidents from January 2014.”
In another incident, a woman was taken to theatre for removal of a suspected ectopic pregnancy, where a foetus implants outside the womb and cannot survive.
Before the procedure, the surgeon did not review a previous scan which showed one of her kidneys was in her pelvis.
“During the procedure the surgeon identified a structure thought to be the ectopic pregnancy, and removed this,” the report said.
However that was then identified as a pelvic kidney. The woman was not found to have an ectopic pregnancy.
After the error, staff were reminded of the guidelines for treating the condition and there was a meeting about the incident.
In two cases, patients were given too much adrenaline – one who was given ten times the prescribed dose then lost vision in one eye. The sight loss was later found to have occurred at the time of the overdose.
In another incident, a patient on the Critical Care Unit had been prescribed adrenaline at a rate of 5mls per hour following surgery, but it was mistakenly given at 50mls an hour. They needed further surgery but later recovered.
A further incident happened when a patient with diabetes began to deteriorate and was supposed to be monitored every two hours, but this did not happen. The next morning they could not be woken and were treated, but there were delays.
The patient continued to deteriorate due to their underlying illness and died the next morning. A post mortem confirming the cause of death is awaited.
There was also an outbreak of MRSA infection of the skin of mothers who had been discharged from the post-natal ward at LGI. Apologies were given to those affected.
In all cases, the incidents were investigated and moves made to prevent them recurring.
This article is courtesy of the Yorkshire Evening Post.
Two patients also received adrenaline overdoses, there was an outbreak of MRSA among new mums and staff failed to respond when a patient deteriorated, according to the document.
It details 16 serious incidents recorded by Leeds Teaching Hospitals NHS Trust in May and June, with 11 of these pressure ulcers.
The report, by chief medical officer Dr Yvette Oade, says there has been an increase since 2013 in the number of serious incidents.
She said: “Whilst this reflects our reporting and learning culture, this is also attributable to a decision that we took to report all category 3 pressure ulcers as serious incidents from January 2014.”
In another incident, a woman was taken to theatre for removal of a suspected ectopic pregnancy, where a foetus implants outside the womb and cannot survive.
Before the procedure, the surgeon did not review a previous scan which showed one of her kidneys was in her pelvis.
“During the procedure the surgeon identified a structure thought to be the ectopic pregnancy, and removed this,” the report said.
However that was then identified as a pelvic kidney. The woman was not found to have an ectopic pregnancy.
After the error, staff were reminded of the guidelines for treating the condition and there was a meeting about the incident.
In two cases, patients were given too much adrenaline – one who was given ten times the prescribed dose then lost vision in one eye. The sight loss was later found to have occurred at the time of the overdose.
In another incident, a patient on the Critical Care Unit had been prescribed adrenaline at a rate of 5mls per hour following surgery, but it was mistakenly given at 50mls an hour. They needed further surgery but later recovered.
A further incident happened when a patient with diabetes began to deteriorate and was supposed to be monitored every two hours, but this did not happen. The next morning they could not be woken and were treated, but there were delays.
The patient continued to deteriorate due to their underlying illness and died the next morning. A post mortem confirming the cause of death is awaited.
There was also an outbreak of MRSA infection of the skin of mothers who had been discharged from the post-natal ward at LGI. Apologies were given to those affected.
In all cases, the incidents were investigated and moves made to prevent them recurring.
This article is courtesy of the Yorkshire Evening Post.
Monday, 18 August 2014
Wrong site surgeries remain top hospital mistake
The surgeon(s), anesthesiologist, scrub nurse, circulating nurse, the surgical techs, and residents stand in the surgical suite. Also in the room is a patient prepared for surgery. The team is going to amputate his lower left leg because he has complications from diabetes. Before performing the procedure, the surgical team forms a huddle to review the surgery that is before them and to ground themselves. When the surgery is completed, instead of the patient’s lower left leg being amputated the team amputated the patient’s lower right leg.
Though statistics vary widely, The Joint Commission, an organization which governs the accreditation of health care organizations, suggests that wrong site surgeries occur 40-60 times in the U.S. each week. Wrong site surgeries are considered to be sentinel events, unexpected occurrences involving psychological injury or serious physical injury or death . The Joint Commission requires sentinel events to be reported and investigated so that the root cause of the mistake can be determined. According to the governing body, breakdown in communication is the primary culprit for wrong site surgeries. After analysis, it has been found that 85 percent of wrong site surgeries occur because of inadequate planning. 72 percent have been attributed to defects in surgeons’ “time outs.” Surgeon “time outs” are breaks taken before a procedure begins, to ensure that all of the details regarding the forthcoming surgery are correct.
Most wrong site surgeries occur during orthopedic, urologic, and neuro-surgical procedures. Odds of wrong site surgeries increase when the surgery involves multiple procedures. For example, when a trauma patient has multiple fractures, surgical teams may make mistakes on which sites require operation.
“Around the country, surgical teams have adopted the practice of forming these huddles or time outs before surgeries,” said Sara Perkins, a Manager of Employee Health at a local hospital in Vancouver, Wash. Perkins, however, is not a surgical nurse. Speaking about the time out procedure her hospital utilizes, Perkins said, “The objective is to confirm that the patient before the team is going to receive the surgery that is needed. The time out leader explains how the surgery will go and questions are asked and answered before the first incision is made.”
Despite time outs, wrong site surgeries continue to occur throughout the nation’s operating rooms. Sometimes the time outs simply do not take place, as may be the case in a severely life-threatening trauma situation where minutes count in saving the patient’s life. Other times, distractions arise and make it difficult for the whole team to come together. The phone might ring. Previous procedures may go longer than expected, making some team members later to the surgical suite than would be optimal. Staff may be rushed, moving between procedures, so that not all team members are fully engaged in the time out.
In small hospitals that do not have multiple surgical teams, an emergent trauma can require team members to toggle between patients. Surgical suites are generally kept small and cool to facilitate a sterile environment. Exchanging team members after the patient has been prepped and draped has the potential of breaking the sterile environment and is discouraged; nevertheless, it sometimes happens. The new staff may not be fully briefed, unlike the team that was present during the pre-surgical timeout.
The Joint Commission requires healthcare to report them and investigate the root causes as to why each of these events have occurred. Medicaid’s decision to deny funding for procedures and care resulting from wrong site surgeries is fairly new. This effectively puts the financial burden of care for these patients back onto the shoulders of hospitals. Despite this further incentive to only perform surgeries on patients that are needed, wrong site surgeries are still one of the biggest mistakes that hospitals make.
A brochure published by The Joint Commission is listed in the “Sources” section at the end of this article. The brochure suggests that to help reduce risk of medical mistakes and wrong site surgeries, patients should consult with their healthcare provider before surgery, to make sure that they do not take any medication that will create ill effects during or after surgery. Also, the patient is advised to make sure that markings placed on their body before surgery accurately reflects the body part on which the surgery is to take place. The video below demonstrates the World Health Organization’s (WHO) protocol for conducting a pre-surgical time out. Team members identify themselves, their roles, and the procedure that is going to take place. This procedure has reduced the incidence of wrong site surgeries, though they continue to occur.
This article is courtesy of the Liberty Voice.
Though statistics vary widely, The Joint Commission, an organization which governs the accreditation of health care organizations, suggests that wrong site surgeries occur 40-60 times in the U.S. each week. Wrong site surgeries are considered to be sentinel events, unexpected occurrences involving psychological injury or serious physical injury or death . The Joint Commission requires sentinel events to be reported and investigated so that the root cause of the mistake can be determined. According to the governing body, breakdown in communication is the primary culprit for wrong site surgeries. After analysis, it has been found that 85 percent of wrong site surgeries occur because of inadequate planning. 72 percent have been attributed to defects in surgeons’ “time outs.” Surgeon “time outs” are breaks taken before a procedure begins, to ensure that all of the details regarding the forthcoming surgery are correct.
Most wrong site surgeries occur during orthopedic, urologic, and neuro-surgical procedures. Odds of wrong site surgeries increase when the surgery involves multiple procedures. For example, when a trauma patient has multiple fractures, surgical teams may make mistakes on which sites require operation.
“Around the country, surgical teams have adopted the practice of forming these huddles or time outs before surgeries,” said Sara Perkins, a Manager of Employee Health at a local hospital in Vancouver, Wash. Perkins, however, is not a surgical nurse. Speaking about the time out procedure her hospital utilizes, Perkins said, “The objective is to confirm that the patient before the team is going to receive the surgery that is needed. The time out leader explains how the surgery will go and questions are asked and answered before the first incision is made.”
Despite time outs, wrong site surgeries continue to occur throughout the nation’s operating rooms. Sometimes the time outs simply do not take place, as may be the case in a severely life-threatening trauma situation where minutes count in saving the patient’s life. Other times, distractions arise and make it difficult for the whole team to come together. The phone might ring. Previous procedures may go longer than expected, making some team members later to the surgical suite than would be optimal. Staff may be rushed, moving between procedures, so that not all team members are fully engaged in the time out.
In small hospitals that do not have multiple surgical teams, an emergent trauma can require team members to toggle between patients. Surgical suites are generally kept small and cool to facilitate a sterile environment. Exchanging team members after the patient has been prepped and draped has the potential of breaking the sterile environment and is discouraged; nevertheless, it sometimes happens. The new staff may not be fully briefed, unlike the team that was present during the pre-surgical timeout.
The Joint Commission requires healthcare to report them and investigate the root causes as to why each of these events have occurred. Medicaid’s decision to deny funding for procedures and care resulting from wrong site surgeries is fairly new. This effectively puts the financial burden of care for these patients back onto the shoulders of hospitals. Despite this further incentive to only perform surgeries on patients that are needed, wrong site surgeries are still one of the biggest mistakes that hospitals make.
A brochure published by The Joint Commission is listed in the “Sources” section at the end of this article. The brochure suggests that to help reduce risk of medical mistakes and wrong site surgeries, patients should consult with their healthcare provider before surgery, to make sure that they do not take any medication that will create ill effects during or after surgery. Also, the patient is advised to make sure that markings placed on their body before surgery accurately reflects the body part on which the surgery is to take place. The video below demonstrates the World Health Organization’s (WHO) protocol for conducting a pre-surgical time out. Team members identify themselves, their roles, and the procedure that is going to take place. This procedure has reduced the incidence of wrong site surgeries, though they continue to occur.
This article is courtesy of the Liberty Voice.
Wednesday, 6 August 2014
Fears after NHS surgery mistakes
At least 35 patients have had the wrong part of their body operated on in the past five years, new figures reveal.
Errors include one patient having a needle thrust into the wrong side of their chest during an emergency procedure and several patients having the wrong part of their head operated on.
Patients' groups have hit out at the string of mistakes, saying it was both a tragedy and frightening such mistakes could happen.
Patients are visited by consultant surgeons and anaesthetists before operations and it is standard practice for medics to "draw" on the operation site before the patient goes into theatre.
The details of botched surgeries follow the revelation last month that the Scottish NHS spent more than £186 million on compensation in the past five years.
Four out of Scotland's 14 health boards admitted to operating on the wrong body parts. NHS Greater Glasgow and Clyde admitted there had been 12 occasions in which staff had mistakenly operated on the wrong part of the body. Three involved operations on the head.
A document, released through the Freedom of Information Act, stated the patient's head had been "shaved, prepped, incision made and with the skin open a small amount of dissection was carried out on right side" when it should have been on the left.
NHS Lanarkshire said there had been two occasions when their staff had carried out procedures on the wrong part of the body. Both involved patients being treated for "squints" and they were given "injections to the wrong muscle" in their eye.
NHS Tayside revealed it had 20 incidents in which staff had incorrectly carried out operations or procedures on the wrong part of their body.
NHS Lothian admitted to "five or fewer" errors but refused to give details, claiming patients could be identified. Fife said it did not hold the details. The other boards said there had been no mistakes.
Jean Turner, executive director of Scotland Patients Association said: "The tragedy is that these are not just statistics, but people this has happened to."
A Scottish Government spokeswoman said: "While any surgical error is regrettable, it is important to put these figures in context as they reflect a tiny number of the 1.2 million procedures carried out safely each year.
"We have witnessed a 23 per cent reduction in surgical mortality since 2008, have implemented the World Health Organisation surgical checklist and are committed to further improvements."
This article is courtesy of the Herald Scotland.
Errors include one patient having a needle thrust into the wrong side of their chest during an emergency procedure and several patients having the wrong part of their head operated on.
Patients' groups have hit out at the string of mistakes, saying it was both a tragedy and frightening such mistakes could happen.
Patients are visited by consultant surgeons and anaesthetists before operations and it is standard practice for medics to "draw" on the operation site before the patient goes into theatre.
The details of botched surgeries follow the revelation last month that the Scottish NHS spent more than £186 million on compensation in the past five years.
Four out of Scotland's 14 health boards admitted to operating on the wrong body parts. NHS Greater Glasgow and Clyde admitted there had been 12 occasions in which staff had mistakenly operated on the wrong part of the body. Three involved operations on the head.
A document, released through the Freedom of Information Act, stated the patient's head had been "shaved, prepped, incision made and with the skin open a small amount of dissection was carried out on right side" when it should have been on the left.
NHS Lanarkshire said there had been two occasions when their staff had carried out procedures on the wrong part of the body. Both involved patients being treated for "squints" and they were given "injections to the wrong muscle" in their eye.
NHS Tayside revealed it had 20 incidents in which staff had incorrectly carried out operations or procedures on the wrong part of their body.
NHS Lothian admitted to "five or fewer" errors but refused to give details, claiming patients could be identified. Fife said it did not hold the details. The other boards said there had been no mistakes.
Jean Turner, executive director of Scotland Patients Association said: "The tragedy is that these are not just statistics, but people this has happened to."
A Scottish Government spokeswoman said: "While any surgical error is regrettable, it is important to put these figures in context as they reflect a tiny number of the 1.2 million procedures carried out safely each year.
"We have witnessed a 23 per cent reduction in surgical mortality since 2008, have implemented the World Health Organisation surgical checklist and are committed to further improvements."
This article is courtesy of the Herald Scotland.
Monday, 19 May 2014
Man given vasectomy by MISTAKE after going into hospital for minor op could get £100,000 compensation
A man who went into hospital for a minor operation was given a vasectomy instead, it emerged yesterday.
The surgeon’s ‘catastrophic’ blunder meant the unnamed patient, thought to be of an age at which he hoped to father children, was left sterile.
Doctors, who were meant to be performing a straightforward urological procedure, apologised unreservedly and operated again to reverse the vasectomy.
However, he faces an anxious wait to find out whether he is now fertile again.
In one case in two, a man who has a vasectomy reversed is unable to impregnate his partner naturally and the success rate for fertility treatment is even lower, at about one in four.
Clinical negligence lawyers say the patient could be entitled to a six-figure compensation payout from the hospital.
The mistake is classed by the NHS as a ‘never’ event – one which should never happen if all the proper surgical procedures are followed.
It happened at Royal Liverpool Hospital in February, and the surgeon has been barred from operating while an investigation is concluded.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said: ‘This is a truly shocking and worrying case.
‘From what we know, there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'In a worst case scenario – sterility in a younger man with no children – the trust might be liable for a figure in excess of £100,000 in compensation.’
The hospital trust’s medical director, Dr Peter Williams, confirmed the blunder, adding: ‘We have apologised.
'We greatly regret the distress this has caused him. We are investigating this fully to understand why it occurred and how we can ensure it does not happen again.’
The hospital has refused to give the patient’s age citing medical confidentiality.
However, the fact that a reversal was attempted indicates that he had hoped either to start a family or to have more children.
Trust chief executive Aidan Kehoe told a board meeting it appeared that a World Health Organisation surgical safety checklist had not been followed.
Last year, Health Secretary Jeremy Hunt revealed there had been 326 ‘never’ events in 2011/12.
Among them 161 patients with foreign objects such as swabs left in their bodies, 70 suffering wrong-site surgery – where the wrong part of the body is operated upon – and 41 given incorrect implants.
Another 148 such incidents were recorded by NHS England between April and September last year.
This article is courtesy from The Daily Mail.
The surgeon’s ‘catastrophic’ blunder meant the unnamed patient, thought to be of an age at which he hoped to father children, was left sterile.
Doctors, who were meant to be performing a straightforward urological procedure, apologised unreservedly and operated again to reverse the vasectomy.
However, he faces an anxious wait to find out whether he is now fertile again.
In one case in two, a man who has a vasectomy reversed is unable to impregnate his partner naturally and the success rate for fertility treatment is even lower, at about one in four.
Clinical negligence lawyers say the patient could be entitled to a six-figure compensation payout from the hospital.
The mistake is classed by the NHS as a ‘never’ event – one which should never happen if all the proper surgical procedures are followed.
It happened at Royal Liverpool Hospital in February, and the surgeon has been barred from operating while an investigation is concluded.
Ian Cohen, clinical negligence lawyer at Slater & Gordon, said: ‘This is a truly shocking and worrying case.
‘From what we know, there has been a catastrophic breakdown in procedure, as simple checks designed to ensure the correct operation is carried out on the right patient seem to have failed.
'In a worst case scenario – sterility in a younger man with no children – the trust might be liable for a figure in excess of £100,000 in compensation.’
The hospital trust’s medical director, Dr Peter Williams, confirmed the blunder, adding: ‘We have apologised.
'We greatly regret the distress this has caused him. We are investigating this fully to understand why it occurred and how we can ensure it does not happen again.’
The hospital has refused to give the patient’s age citing medical confidentiality.
However, the fact that a reversal was attempted indicates that he had hoped either to start a family or to have more children.
Trust chief executive Aidan Kehoe told a board meeting it appeared that a World Health Organisation surgical safety checklist had not been followed.
Last year, Health Secretary Jeremy Hunt revealed there had been 326 ‘never’ events in 2011/12.
Among them 161 patients with foreign objects such as swabs left in their bodies, 70 suffering wrong-site surgery – where the wrong part of the body is operated upon – and 41 given incorrect implants.
Another 148 such incidents were recorded by NHS England between April and September last year.
This article is courtesy from The Daily Mail.
Saturday, 14 September 2013
Extreme 'never event' NHS blunders such as operating on the wrong body part or giving lethal doses of painkillers double in a year
The number of hospital mistakes deemed so serious they should never have happened has almost doubled in a single year.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘You feel guilty because when she [was] talking to us she kept saying she wanted to come out, and we kept saying, ‘You can’t come out, mum, until you get better,’
‘You feel angry after, because you think someone’s killed your mum. No, they probably didn’t do it on purpose but that’s how it feels. You feel that somebody’s killed her.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy of the Daily Mail.
There were 299 ‘never’ events in 2012/13, up from 163 in 2011/12, according to the Department of Health’s own figures.
Among 25 types of incidents are surgical instruments left in the body, operations on the wrong body part and fatal errors such as feeding tubes inserted into the lungs and patients given lethal doses of painkillers.
A list of these errors, by hospital, will be published so patients can see where the highest number occur.
NHS England – the organisation in charge of the health service – will release the data four times a year starting from next month.
There are 25 different types of ‘never events’ including surgery on the wrong body part, patients being given lethal doses of painkillers and mothers dying during caesareans.
Others include feeding tubes inserted into the lungs rather than the stomach and staff muddling up patients giving them the wrong treatment or operation.
But medical negligence lawyers believe that thousands of these mistakes occur each year but staff often try and cover them up in case patients try to sue.
NHS England could not explain why the numbers had increased so starkly and said another organisation had been responsible for collecting them in the past.
Mike Durkin, the body’s director of patient safety said: ‘NHS England intends to begin publishing more detailed data on never events on a more regular basis very soon, providing more frequent information on the numbers and kinds of never events that occur in the NHS as part of its wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.
‘Every single never event is one too many and, as Don Berwick (the Government’s tsar on preventing harm) made clear in his recent report, we need to openly and publicly report and address safety problems, not so that people can lay blame inappropriately, but so that we can fully understand and therefore learn more from the safety problems that the NHS, like all healthcare systems, faces.’
One grieving relative described how nurses had mistakenly inserted a feeding tube into her mother’s lungs instead of her stomach.
Speaking anonymously, the victim said staff had also failed to carry out an x-ray to check it was in the right place.
In a recent interview with the BBC she said: ‘You feel guilty because when she [was] talking to us she kept saying she wanted to come out, and we kept saying, ‘You can’t come out, mum, until you get better,’
‘You feel angry after, because you think someone’s killed your mum. No, they probably didn’t do it on purpose but that’s how it feels. You feel that somebody’s killed her.’
Shadow health secretary Andy Burnham said: ‘These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind.
‘Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards under-staffed and nurses over-stretched. That explains why so many nurses say they have considered resigning.
‘The warning signs of an NHS under intense pressure are growing day by day and David Cameron cannot continue to ignore them. He must act to halt the job losses and ensure all hospitals in England have enough staff on the wards to provide safe care.’
This article is courtesy of the Daily Mail.
Saturday, 7 September 2013
Patient at Halifax Hospital has surgery on wrong leg
A patient woke up from surgery at Halifax Hospital Medical Center last month to find her surgeon had operated on the wrong leg.
But, that's not how the cardiovascular surgeon explained it to her, according to a report from Florida's Agency for Health Care Administration, which investigated the July 3 incident. Instead, the surgeon told the patient that her other leg needed to be done anyway. Then he asked her to sign a consent after the fact, according to the report.
Patient 34, as she is referred to in the agency's report, was admitted to the Daytona Beach hospital for vascular disease, which was causing pain in her left leg. She gave her consent to have vascular graft surgery on her left leg. But the surgical staff scheduled the procedure for her right leg.
The surgeon talked with the patient the night before about the left-leg procedure she was to have, and he marked her left leg with a pen, according to the report.
The operating room nurse supervisor said that when she talked to the patient before surgery, the patient said she was having her left leg done, "but [the nurse] still had it in her mind the right leg," the report said.
A nurse anesthetist caught the error after the operation was underway on the wrong leg. She told another nurse who told the surgeon to stop.
The surgeon then proceeded to operate on the left leg, according to the report.
The day after the surgery, the surgeon talked to the patient and her daughter. "I explained to them that the surgery was justified because of her history," the surgeon said, according to an interview with ACHA conducted three weeks after the error.
"I then explained to them that I performed the procedure on the left leg that we obtained the consent for originally, and I asked the patient to sign a consent for the procedure that was done on the right leg."
When asked if he told the patient the surgery was an error, he said, "No, what I described to the patient was that the right side surgery was justified. I did not use the term 'wrong-site surgery'…I was thinking more about myself and justifying what was done to the patient," he said, according to the report.
Two-week delay
Though the hospital administration knew of the error the day it occurred, it did not report it to AHCA for 15 days, according to the report.
"We had a wrong-site surgery. We had a system in place, but we did not proceed in the proper way," said hospital spokesman John Guthrie.
"We self reported. We're not denying it. We have policies in place, and training in place, but the system broke down because of the human element," he said.
Wrong-site surgeries are rare because hospitals have extensive cross-checks in place to verify the correct procedure is being done on the correct patient on the correct side. The last time Halifax had a wrong-site surgery was in 1999, on an incorrect finger, said Guthrie. Halifax Hospital's surgeons perform 8,000 operations a year.
In the first six months of this year, 35 patients in Florida have had operations on the wrong site, according to AHCA data. Six have had the wrong surgery performed, and in one case surgery was performed on the wrong patient.
When asked what took the hospital so long to report the error to state officials, Guthrie said the hospital reported within the allowed time frame, and didn't want to rush the process.
"We knew we were going to change people's lives based on root-cause analysis, so we wanted to find the root cause," Guthrie said.
'Serious threat'
After learning of the incident, the state health-care agency began an intense survey of the hospital from July 22 to July 25. Health officials interviewed the staff involved in the wrong-site surgery, the surgeon and the patient, and observed operating-room management and hygiene procedures.
Agency officials uncovered numerous problems at the 678-bed public hospital, including a cleaning person who washed down the operating room table with the same water she had just used to mop the floor, according to the report.
They also found expired medications on drug carts in use.
The surgeon involved is no longer on staff, said Guthrie. The hospital also suspended the operating-room team involved, and one of the team members no longer works for the hospital.
As a result of their findings, the agency concluded that the hospital was in a state of "immediate jeopardy." An agency letter to Halifax Hospital dated July 30 stated, "The conditions at your facility pose an immediate and serious threat to the health and safety of patients."
Based on the findings, the agency recommended to the federal Centers for Medicare and Medicaid that the hospital's provider agreement be terminated as of Saturday, Aug. 17.
A termination would mean that Halifax Hospital could no longer receive payments for Medicare or Medicaid patients, a population that comprises up to 70 percent of its patients, said Guthrie.
This article is courtesy of Orlando Sentinel.
But, that's not how the cardiovascular surgeon explained it to her, according to a report from Florida's Agency for Health Care Administration, which investigated the July 3 incident. Instead, the surgeon told the patient that her other leg needed to be done anyway. Then he asked her to sign a consent after the fact, according to the report.
Patient 34, as she is referred to in the agency's report, was admitted to the Daytona Beach hospital for vascular disease, which was causing pain in her left leg. She gave her consent to have vascular graft surgery on her left leg. But the surgical staff scheduled the procedure for her right leg.
The surgeon talked with the patient the night before about the left-leg procedure she was to have, and he marked her left leg with a pen, according to the report.
The operating room nurse supervisor said that when she talked to the patient before surgery, the patient said she was having her left leg done, "but [the nurse] still had it in her mind the right leg," the report said.
A nurse anesthetist caught the error after the operation was underway on the wrong leg. She told another nurse who told the surgeon to stop.
The surgeon then proceeded to operate on the left leg, according to the report.
The day after the surgery, the surgeon talked to the patient and her daughter. "I explained to them that the surgery was justified because of her history," the surgeon said, according to an interview with ACHA conducted three weeks after the error.
"I then explained to them that I performed the procedure on the left leg that we obtained the consent for originally, and I asked the patient to sign a consent for the procedure that was done on the right leg."
When asked if he told the patient the surgery was an error, he said, "No, what I described to the patient was that the right side surgery was justified. I did not use the term 'wrong-site surgery'…I was thinking more about myself and justifying what was done to the patient," he said, according to the report.
Two-week delay
Though the hospital administration knew of the error the day it occurred, it did not report it to AHCA for 15 days, according to the report.
"We had a wrong-site surgery. We had a system in place, but we did not proceed in the proper way," said hospital spokesman John Guthrie.
"We self reported. We're not denying it. We have policies in place, and training in place, but the system broke down because of the human element," he said.
Wrong-site surgeries are rare because hospitals have extensive cross-checks in place to verify the correct procedure is being done on the correct patient on the correct side. The last time Halifax had a wrong-site surgery was in 1999, on an incorrect finger, said Guthrie. Halifax Hospital's surgeons perform 8,000 operations a year.
In the first six months of this year, 35 patients in Florida have had operations on the wrong site, according to AHCA data. Six have had the wrong surgery performed, and in one case surgery was performed on the wrong patient.
When asked what took the hospital so long to report the error to state officials, Guthrie said the hospital reported within the allowed time frame, and didn't want to rush the process.
"We knew we were going to change people's lives based on root-cause analysis, so we wanted to find the root cause," Guthrie said.
'Serious threat'
After learning of the incident, the state health-care agency began an intense survey of the hospital from July 22 to July 25. Health officials interviewed the staff involved in the wrong-site surgery, the surgeon and the patient, and observed operating-room management and hygiene procedures.
Agency officials uncovered numerous problems at the 678-bed public hospital, including a cleaning person who washed down the operating room table with the same water she had just used to mop the floor, according to the report.
They also found expired medications on drug carts in use.
The surgeon involved is no longer on staff, said Guthrie. The hospital also suspended the operating-room team involved, and one of the team members no longer works for the hospital.
As a result of their findings, the agency concluded that the hospital was in a state of "immediate jeopardy." An agency letter to Halifax Hospital dated July 30 stated, "The conditions at your facility pose an immediate and serious threat to the health and safety of patients."
Based on the findings, the agency recommended to the federal Centers for Medicare and Medicaid that the hospital's provider agreement be terminated as of Saturday, Aug. 17.
A termination would mean that Halifax Hospital could no longer receive payments for Medicare or Medicaid patients, a population that comprises up to 70 percent of its patients, said Guthrie.
This article is courtesy of Orlando Sentinel.
Tuesday, 3 September 2013
University of Toledo Medical Center denies negligence in kidney transplant case
The University of Toledo Medical Center denies a family's allegations of medical negligence over a botched kidney transplant and wants the Ohio Court of Claims to dismiss the case, according to court filings.
The hospital has said a nurse accidentally threw out a chilled, protective slush containing a viable kidney donated to a Toledo woman by her younger brother in August 2012. The 24-year-old woman, who was suffering from end-stage renal disease, later received a different kidney in Colorado, court records show.
A complaint by the siblings and their family alleged the facility in northwest Ohio was negligent, causing physical and emotional suffering for the patients and emotional distress for their parents. The sister awoke in a recovery area with no incision and initially feared her brother had died in surgery, the complaint said. Her parents worried about their daughter's prognosis and about their son losing a kidney in vain, it said.
The complaint also said the parents and other siblings lost the pair's comfort and companionship because of the alleged negligence.
In documents filed Tuesday, the hospital denied the allegations and sought dismissal of the case. In a specific request to dismiss the counts involving the relatives' alleged losses, it argued that Ohio law doesn't provide for parents and siblings of an affected adult to recover damages for such losses.
A statement from an attorney for the family says adults can recover damages for such losses involving their parents, and the same should be true if the situation is reversed.
The medical center apologized for the error, underwent internal and external reviews, clarified some procedures and temporarily suspended its live kidney donation program, which has since resumed. It has declined to comment on the pending litigation.
The nurse who disposed of the kidney retired, and another who was present and was suspended then fired has sued for wrongful termination. The surgeon in charge of the case no longer oversees renal transplantation for the hospital but continues to perform transplants and is a professor, according to court records.
The eight family members who filed the case, including the patients, are each seeking monetary damages of at least $25,000.
This article is courtesy of The Huffington Post.
The hospital has said a nurse accidentally threw out a chilled, protective slush containing a viable kidney donated to a Toledo woman by her younger brother in August 2012. The 24-year-old woman, who was suffering from end-stage renal disease, later received a different kidney in Colorado, court records show.
A complaint by the siblings and their family alleged the facility in northwest Ohio was negligent, causing physical and emotional suffering for the patients and emotional distress for their parents. The sister awoke in a recovery area with no incision and initially feared her brother had died in surgery, the complaint said. Her parents worried about their daughter's prognosis and about their son losing a kidney in vain, it said.
The complaint also said the parents and other siblings lost the pair's comfort and companionship because of the alleged negligence.
In documents filed Tuesday, the hospital denied the allegations and sought dismissal of the case. In a specific request to dismiss the counts involving the relatives' alleged losses, it argued that Ohio law doesn't provide for parents and siblings of an affected adult to recover damages for such losses.
A statement from an attorney for the family says adults can recover damages for such losses involving their parents, and the same should be true if the situation is reversed.
The medical center apologized for the error, underwent internal and external reviews, clarified some procedures and temporarily suspended its live kidney donation program, which has since resumed. It has declined to comment on the pending litigation.
The nurse who disposed of the kidney retired, and another who was present and was suspended then fired has sued for wrongful termination. The surgeon in charge of the case no longer oversees renal transplantation for the hospital but continues to perform transplants and is a professor, according to court records.
The eight family members who filed the case, including the patients, are each seeking monetary damages of at least $25,000.
This article is courtesy of The Huffington Post.
Thursday, 15 August 2013
Medical negligence case study: Laurence Ball
In May 2005, Laurence Ball contracted a chest infection. After several tests, the firefighter was told that he had a cancerous tumor in the upper left lobe of his lung. He was taken for surgery at Aberdeen Royal Infirmary where doctors removed his entire left lung.
The surgery was seven hours long. When Mr. Ball woke up, he was informed that there had been a mistake. He did not need chemotherapy because he did not have cancer. His lung had been removed unnecessarily.
“For the next few days I was really traumatized and in deep shock,” said Mr. Ball. “I was exhilarated to have survived the operation and then to be told that I didn't have cancer - I could not get my head around the words."
NHS Grampian acknowledged that Mr Ball’s procedure may not have been necessary, but claims it did not find incompetence or negligence in an internal investigation.
"The clinical course of action agreed for Mr Ball was arrived at following the review of all relevant information, test results, scans, x-rays etc, by a multi-disciplinary group of clinicians,” NHS Grampian said in a statement. “It was considered to be the appropriate action based on all this information.”
Mr Ball disagreed with the claim. “The impact of this on my life and my family is hard to imagine," he said. "I have lost everything - my job, my health and I have had years of what should have been a happy retirement stolen from me.
Mr Ball filed legal action and asked for compensation for medical negligence. Since the operation, he has suffered ongoing medical issues including a deadly collapsed lung. Because he was unable to work, he was also forced to sell his home.
After rejecting NHS Grantham’s initial offer to settle out of court, the former firefighter is seeking a six-figure sum in compensation.
If you, or anyone you know, has been a victim of medical misdiagnosis you too can file a claim for compensation by completing a short Start a Claim form at the TRUE Medical Negligence website.
The surgery was seven hours long. When Mr. Ball woke up, he was informed that there had been a mistake. He did not need chemotherapy because he did not have cancer. His lung had been removed unnecessarily.
“For the next few days I was really traumatized and in deep shock,” said Mr. Ball. “I was exhilarated to have survived the operation and then to be told that I didn't have cancer - I could not get my head around the words."
NHS Grampian acknowledged that Mr Ball’s procedure may not have been necessary, but claims it did not find incompetence or negligence in an internal investigation.
"The clinical course of action agreed for Mr Ball was arrived at following the review of all relevant information, test results, scans, x-rays etc, by a multi-disciplinary group of clinicians,” NHS Grampian said in a statement. “It was considered to be the appropriate action based on all this information.”
Mr Ball disagreed with the claim. “The impact of this on my life and my family is hard to imagine," he said. "I have lost everything - my job, my health and I have had years of what should have been a happy retirement stolen from me.
Mr Ball filed legal action and asked for compensation for medical negligence. Since the operation, he has suffered ongoing medical issues including a deadly collapsed lung. Because he was unable to work, he was also forced to sell his home.
After rejecting NHS Grantham’s initial offer to settle out of court, the former firefighter is seeking a six-figure sum in compensation.
If you, or anyone you know, has been a victim of medical misdiagnosis you too can file a claim for compensation by completing a short Start a Claim form at the TRUE Medical Negligence website.
Sunday, 4 August 2013
Hospital, surgeon facing hundreds of lawsuits over phantom surgeries
An upstate New York surgeon and his hospital are being accused of greed and negligence in a series of malpractice lawsuits.
Dr. Spyros Panos, formerly a surgeon at Saint Francis Hospital in Poughkeepsie, N.Y., are facing hundreds of malpractice lawsuits over accusations he sliced people open and sewed them back up without actually performing any procedures, or that he performed the wrong surgery.
Scheduling as many as 22 surgeries a day, an almost unheard of workload, Panos was billing for work never completed and his out of control greed resulted in the death of a 76-year-old woman, one of the lawsuits alleges.
Panos reportedly would schedule up to 22 surgeries a day, most surgeons only schedule 32 procedures a month, according to industry statistics quoted by ABC News.
Debra Nenni McNamee alleges that in 2009 Panos was to have performed surgery on her 76-year-old mother Constance Nenni’s left knee to repair damage caused by arthritis, according to ABC. Panos is said to have described the procedure as ‘a simple in and out.’
The procedure involved a small camera being inserted into Nenni’s knee to help clean out any dead or damaged tissue found, a fairly routine procedure. McNamee claims that less than 24 hours after the surgery, Nenni died of a pulmonary embolism said to have been caused by a blood clot that broke free and blocked the lung’s main artery, according to reports.
Though not a common occurrence from knee surgery, older adults are more prone to such complications from any type of surgery. The Dutchess County (NY) medical examiner’s report, purportedly, is what did Panos in.
Panos allegedly had fudged all the post-surgery notes related to the six procedures he had performed on the family patriarch. The medical examiner's autopsy showed no evidence that he had ever removed torn cartilage, smoothed areas of excess wear or removed soft tissue from within the knee joint – he simply opened and closed her knee without so much as a single bit of repair, the Poughkeepsie Journal originally reported.
‘He put her under anesthesia, placed the scope in her knee and then closed her up without performing any surgery,’ Brian Brown, McNamee’s lawyer told ABC. ‘The reports showed no hardware in place and, certainly, no evidence of a total knee reconstruction.’
McNamee’s case wasn’t a one-off, according to several reports. Former patients have brought a total of 250 malpractice suits against Mid-Hudson Medical Group, parent of Saint Francis and Vassar Hospitals, and Panos, according to reports. Both hospitals, located in Poughkeepsie, have declined on multiple occasions to comment, as has Panos. A message seeking comment left with Brent Fleming, Panos' attorney, was not returned.
In another instance, Panos is accused of having performed the wrong surgery.
Barbara Murphy was to have a broken collarbone fixed by Panos in 2010, instead he operated on her rotator cuff as if it was broken, despite there being no evidence to suggest that procedure was necessary, she told the Journal.
Making matters even worse, the Mid-Hudson Medical Group is in the midst of a deal that some believe is an effort to evade liability over Panos, who has since been fired and is also under a federal investigation.
Rival Mount Kisco Medical Group and Mid-Hudson are trying combine assets in a transaction that will transfer ownership of current Mid-Hudson asset to Mount Kisco, leaving Mid-Hudson as nothing more than a shell company that would eventually dissolve, according to the Journal.
Though both sides are adamant the merger is about providing the best care to patients in the region, not everyone is convinced.
‘They are taking what’s valuable and will leave a defunct shell,’ said JT Wisell, an attorney representing 152 plaintiffs suing Panos.
Explaining that Mount Kisco would take Mid-Hudson’s doctors, and its revenue, financial expert Stephen Schulman told the paper that ‘you can’t sue someone with no money.’
This article is courtesy of the Daily Mail.
Dr. Spyros Panos, formerly a surgeon at Saint Francis Hospital in Poughkeepsie, N.Y., are facing hundreds of malpractice lawsuits over accusations he sliced people open and sewed them back up without actually performing any procedures, or that he performed the wrong surgery.
Scheduling as many as 22 surgeries a day, an almost unheard of workload, Panos was billing for work never completed and his out of control greed resulted in the death of a 76-year-old woman, one of the lawsuits alleges.
Panos reportedly would schedule up to 22 surgeries a day, most surgeons only schedule 32 procedures a month, according to industry statistics quoted by ABC News.
Debra Nenni McNamee alleges that in 2009 Panos was to have performed surgery on her 76-year-old mother Constance Nenni’s left knee to repair damage caused by arthritis, according to ABC. Panos is said to have described the procedure as ‘a simple in and out.’
The procedure involved a small camera being inserted into Nenni’s knee to help clean out any dead or damaged tissue found, a fairly routine procedure. McNamee claims that less than 24 hours after the surgery, Nenni died of a pulmonary embolism said to have been caused by a blood clot that broke free and blocked the lung’s main artery, according to reports.
Though not a common occurrence from knee surgery, older adults are more prone to such complications from any type of surgery. The Dutchess County (NY) medical examiner’s report, purportedly, is what did Panos in.
Panos allegedly had fudged all the post-surgery notes related to the six procedures he had performed on the family patriarch. The medical examiner's autopsy showed no evidence that he had ever removed torn cartilage, smoothed areas of excess wear or removed soft tissue from within the knee joint – he simply opened and closed her knee without so much as a single bit of repair, the Poughkeepsie Journal originally reported.
‘He put her under anesthesia, placed the scope in her knee and then closed her up without performing any surgery,’ Brian Brown, McNamee’s lawyer told ABC. ‘The reports showed no hardware in place and, certainly, no evidence of a total knee reconstruction.’
McNamee’s case wasn’t a one-off, according to several reports. Former patients have brought a total of 250 malpractice suits against Mid-Hudson Medical Group, parent of Saint Francis and Vassar Hospitals, and Panos, according to reports. Both hospitals, located in Poughkeepsie, have declined on multiple occasions to comment, as has Panos. A message seeking comment left with Brent Fleming, Panos' attorney, was not returned.
In another instance, Panos is accused of having performed the wrong surgery.
Barbara Murphy was to have a broken collarbone fixed by Panos in 2010, instead he operated on her rotator cuff as if it was broken, despite there being no evidence to suggest that procedure was necessary, she told the Journal.
Making matters even worse, the Mid-Hudson Medical Group is in the midst of a deal that some believe is an effort to evade liability over Panos, who has since been fired and is also under a federal investigation.
Rival Mount Kisco Medical Group and Mid-Hudson are trying combine assets in a transaction that will transfer ownership of current Mid-Hudson asset to Mount Kisco, leaving Mid-Hudson as nothing more than a shell company that would eventually dissolve, according to the Journal.
Though both sides are adamant the merger is about providing the best care to patients in the region, not everyone is convinced.
‘They are taking what’s valuable and will leave a defunct shell,’ said JT Wisell, an attorney representing 152 plaintiffs suing Panos.
Explaining that Mount Kisco would take Mid-Hudson’s doctors, and its revenue, financial expert Stephen Schulman told the paper that ‘you can’t sue someone with no money.’
This article is courtesy of the Daily Mail.
Friday, 19 July 2013
Medical negligence case study: Surinder Venables
A doctor who mistakenly removed part of a patient’s bowel after confusing it with abnormal tissue had a history of negligence that had gone unreported by the hospital’s trust.
Pathologist Ian Calder gave the patient’s cause of death as a gastric haemorrhage, multiple organ failure and inflammation of the abdomen due to perforation of the uterus.
Not only did Dr Nikolaos Papanikolaou fail to recognize an organ, he also punctured the patient’s uterus. Forty nine year old Surinder Venables died from cardiac arrest one month after her severely botched procedure. Her family was horrified to learn that Dr Papanikolaou had previously left swabs in his patients, failed to recognize when emergency surgical procedures were necessary, and was accused of causing the stillbirth of an infant.
None of Dr Papanikolaou’s errors had been reported to the General Medical Council (GMC). The Council was not aware of any complaints against the doctor until a patient’s father complained to them in 2010. This started an inquiry which found that Dr Papanikolaou was an extremely poor record keeper, mismanaged multiple decisions, and was overall careless.
After the inquiry, the GMC is considering taking Dr Papanikolaou off of the registrar.
Some have called the NHS negligent because of its reporting policies concerning doctors. "His practices should have been looked into deeply and if there was any doubt whatsoever that he should have been reported to the General Medical Council,” said David Marjara, Ms Venables brother.
"These people should be investigated properly by the hospital and the NHS and then they should not be allowed to work."
Ms Venables left behind a partner and two daughters. The family is pursuing a negligence claim for compensation against the trust. However, they are choosing to remember the positives about their lost love one. Ms Venables partner, Alan Chapman, had this to say about her: “She was always helping others, always with a smile, and once you met her you felt like you had known her for ages.”
If you, or anyone you know, has been a victim of medical negligence and you'd like to claim compensation simply add your details to the quick Start a Claim form at TRUE Solicitors and they'll get back to you within 2 working hours.
Pathologist Ian Calder gave the patient’s cause of death as a gastric haemorrhage, multiple organ failure and inflammation of the abdomen due to perforation of the uterus.
Not only did Dr Nikolaos Papanikolaou fail to recognize an organ, he also punctured the patient’s uterus. Forty nine year old Surinder Venables died from cardiac arrest one month after her severely botched procedure. Her family was horrified to learn that Dr Papanikolaou had previously left swabs in his patients, failed to recognize when emergency surgical procedures were necessary, and was accused of causing the stillbirth of an infant.
None of Dr Papanikolaou’s errors had been reported to the General Medical Council (GMC). The Council was not aware of any complaints against the doctor until a patient’s father complained to them in 2010. This started an inquiry which found that Dr Papanikolaou was an extremely poor record keeper, mismanaged multiple decisions, and was overall careless.
After the inquiry, the GMC is considering taking Dr Papanikolaou off of the registrar.
Some have called the NHS negligent because of its reporting policies concerning doctors. "His practices should have been looked into deeply and if there was any doubt whatsoever that he should have been reported to the General Medical Council,” said David Marjara, Ms Venables brother.
"These people should be investigated properly by the hospital and the NHS and then they should not be allowed to work."
Ms Venables left behind a partner and two daughters. The family is pursuing a negligence claim for compensation against the trust. However, they are choosing to remember the positives about their lost love one. Ms Venables partner, Alan Chapman, had this to say about her: “She was always helping others, always with a smile, and once you met her you felt like you had known her for ages.”
If you, or anyone you know, has been a victim of medical negligence and you'd like to claim compensation simply add your details to the quick Start a Claim form at TRUE Solicitors and they'll get back to you within 2 working hours.
Thursday, 20 June 2013
She went in to have her appendix out, instead they removed an ovary... but that was just the start
The inquest is over, but there is no peace, no moving on, for the family of Maria De Jesus. They wonder how they will ever come to terms with her death, for to do that there must be acceptance, some sort of understanding.
But Maria’s death, the manner of it, makes no sense at all. Admitted to hospital at five months’ pregnant with severe abdominal pains, she was told she had appendicitis and needed her appendix removed.
Why, her grieving husband and three children ask themselves, were two trainee surgeons permitted to carry out the procedure without a consultant present? And how on earth did they manage to mistake her ovary for the appendix and remove the wrong organ?
Why, when it was established in a laboratory that the organ was not an appendix at all, did the lab technicians not bother to notify anyone of this fact?
Why did they log the details of this catastrophic mistake on to a computer, as though it were a routine report, and forget about it? Why did the person who commissioned the report never bother to seek out the results? From the day she was admitted on October 21, 2011, until her death three weeks later on November 11, Mrs De Jesus remained in severe pain and was in and out of intensive care.
Yet it was not until two days before her death that a consultant finally looked at her notes and stared in disbelief at the laboratory report stating there was ‘no appendix tissue’ present.
But by then it was too late. Mrs De Jesus had sepsis and, after suffering a miscarriage, died on the operating table hours later during a second operation to remove the appendix.
She was just 32, a beautiful mother-of-three who had been excitedly awaiting the birth of her fourth child.
Last week, Mrs De Jesus’s husband, Adelino, listened to the harrowing details of his wife’s last weeks at her inquest in East London. He remains shell-shocked. Mr and Mrs De Jesus’s sons Pedro, nearly 17, and Andre, who has just turned 16, are full of anger. Their ten-year-old sister Catarina, who has inherited her mother’s beauty, has retreated into herself.
My wife didn’t stand a chance,’ says Mr De Jesus. ‘She spent the last three weeks of her life in agony. She was beautiful, full of life, a wonderful mother. I can’t believe what they did to her. She was treated like an animal. I believe she was unlawfully killed.’
The details of Maria De Jesus’s mistreatment at Queen’s Hospital in Romford, Essex, are truly shocking.
Neglect, disregard for protocols, incompetence, a total absence of inter-departmental communication. Everything that could go wrong, did go wrong.
Her family want the full story told because they believe the medical staff responsible for the catastrophic errors that led to her death should be held accountable.
Originally from Funchal on the Portuguese island of Madeira, Mr and Mrs De Jesus married in 1996 and moved to England in 2005 to seek a better life for their family. The recession in Portugal had hit them badly. Mrs De Jesus’s full name was Maria Joao; in England she became known as Maria.
Initially, the couple found work with a family in South London, with Maria working as a nanny and her husband doing chauffeuring.
But living in London was expensive and, in 2007, the family moved to a spacious house in Becontree, Essex, and Maria started work as a teaching assistant at a local school.
On Friday, October 21, 2011, and five months’ pregnant, Mrs De Jesus began feeling unwell at work. Her husband took her to a walk-in centre, where she was told she needed hospital treatment.
On arrival at Queen’s Hospital in Romford, Essex, she was admitted. ‘There was uncertainty as to what was wrong,’ recalls Mr De Jesus.
‘The next day, the doctors said they needed to operate on her kidneys, then, the day after that, on the Sunday, they said they needed to take her appendix out.’
Mr De Jesus and his wife’s sister, Ana Caldeira, were at the hospital with Maria before she went into theatre.
‘We were told it would be a 30-minute procedure,’ recalls Ms Caldeira, a 35-year-old teacher at a special needs school and mother-of-two.
‘But Maria Joao went in at 3pm and didn’t come out till 6pm and was taken straight to intensive care.
We had no idea the operation was being done by trainee surgeons, without a consultant present.
When we later found this out we were profoundly shocked and disbelieving.
‘One of the consultants said he needed to talk to us. He said he’d been called in during the middle of the operation because the other surgeons had cut her uterus accidentally and they needed to stop the bleed. The blood loss meant she also needed a blood transfusion.’
Mrs De Jesus spent the next eight days between intensive care and the maternity ward. ‘She felt very unwell,’ says Mr De Jesus. ‘She was vomiting, her heartbeat was up, she was heavily medicated on painkillers.’
But Mrs De Jesus was declared fit to be discharged on October 31. On the same day, the results of the tests on the organ that had been removed were put onto a computer system accessible to hospital staff.
But in fact, the inquest heard, laboratory staff had first become aware the organ was not an appendix about four days before that, around October 27.
‘I just can’t understand how nobody said anything,’ says Mr De Jesus. ‘It seems incredible to me.’ If someone had been notified, Mrs De Jesus might have been saved. As the coroner at Mrs De Jesus’s inquest recorded in his narrative verdict: ‘The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.’
Mrs De Jesus spent the next eight days between intensive care and the maternity ward. ‘She felt very unwell,’ says Mr De Jesus. ‘She was vomiting, her heartbeat was up, she was heavily medicated on painkillers.’
But Mrs De Jesus was declared fit to be discharged on October 31. On the same day, the results of the tests on the organ that had been removed were put onto a computer system accessible to hospital staff.
But in fact, the inquest heard, laboratory staff had first become aware the organ was not an appendix about four days before that, around October 27.
‘I just can’t understand how nobody said anything,’ says Mr De Jesus. ‘It seems incredible to me.’ If someone had been notified, Mrs De Jesus might have been saved. As the coroner at Mrs De Jesus’s inquest recorded in his narrative verdict: ‘The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.’
Ms Caldeira adds: ‘We still don’t know why a consultant wasn’t present at the original operation. I think those two trainee surgeons who operated on her were arrogant, they thought they could do it by themselves.’
That day, Mrs De Jesus underwent the drainage procedure. It seemed to go well, but at midnight that night, Mr De Jesus took a call from the hospital saying to come to the hospital immediately.
He and Maria’s sister, who was staying at the house, made a frantic dash by car and when they arrived, were told that Maria was miscarrying. ‘She was moaning and crying and shaking,’ says Ms Caldeira. ‘I begged them to do a Caesarean but they refused.’
Mr De Jesus recalls the moment his baby son was born. ‘I held him and I felt that he was moving, that he was alive, but then the staff took him away from me and told me he was dead, that he had been stillborn.’
Maria, Ana, and Adelino were left alone for 45 minutes while staff dealt with another emergency.
‘Maria began to deteriorate during this time,’ says Mr De Jesus. ‘There was blood everywhere, her oxygen levels were low, her eyes were closed, she was gasping for breath. Suddenly lots of people were coming in and out.
‘The senior consultant came back and said they had a feeling Maria had septicaemia and they had to do something about it.’
Ms Caldeira goes on: ‘I asked one of the surgeons if Maria could die and he replied no, there was no life risk. The only thing that might happen was that they would have to remove the uterus.’
There followed an awful scene in which, Ms Caldeira says, the medical team were shouting at her sister to sign the consent form, when she was clearly in no fit state to do so. ‘I kept saying, let her husband sign, but they wouldn’t listen. I don’t know why, perhaps because Adelino doesn’t speak very good English.
‘Eventually I forced a pen between her finger and said: “If you don’t sign the form, you’ll die,” and she scribbled something down. We said goodbye to her as she was taken down to theatre. She was semi-conscious.’
Mr De Jesus and Ms Caldeira drove home to check on the children, but at 8am there was another phone call from the hospital, requesting that Mr De Jesus return immediately.
‘I said to Ana: “Oh my God, something bad has happened”, but Ana tried to reassure me that the operation had not gone as well as it should have, that it was no worse than that.’
But Ana, too, had a feeling about it and as soon as she and Mr De Jesus were shown into a room she said: ‘Just tell me, is she alive or dead?’ ‘The consultant replied: “I’m so sorry, she passed away”,’ recalls Ms Caldeira.
‘Adelino was so distraught he started having chest pains and had to be put in a bed. The doctors later explained that the operation had gone well, her heartbeat was fine, and they had removed the appendix, which had a pelvic abscess around it.
‘Then suddenly without warning she went. She had gone into cardiac arrest. They tried everything to bring her back but her septicaemia was so advanced it had caused all her major organs to shut down.’
Mr De Jesus and Ana returned home and Ana went upstairs while the children’s father told them their mother was dead.
‘I don’t want to talk about that moment,’ says Mr De Jesus. ‘All I will say is that they were all very insistent that they wanted to see her.
‘I took them to her and she was all swollen and looked nothing like herself. It offered them no comfort whatsoever — quite the contrary.’
The loss of Maria has, of course, devastated the family. Adelino, who faces no prospect of being able to work with three children to look after, is desolate and visits her grave every day.
‘Maria Joao was the heart of our family,’ he says. ‘She was so beautiful and fun-loving and did things with the kids like white water rafting. Easter and Christmas and birthdays were big occasions for us and Maria would cook and organise everything.
‘The three children must go through life without a mother. Pedro and Andre feel very angry at her treatment.
‘Catarina will go through her teenage years, getting married, having children, without her mother. She was her mother’s girl. We will never get over this. She is irreplaceable.’
There remains a lot of anger. ‘No one was leading Maria Joao’s case, no one was in charge,’ says Ms Caldeira. ‘It was being handed over, passed around. There was no communication, no organisation.
‘The treatment by some of those doctors was appalling, but amid all the bad there was good as well, good doctors, who did their best. But it was too late.’
Maria’s son, Pedro, says simply: ‘All those who contributed to my mother’s death should be jailed.’
So what, if any, action will be taken against these members of staff, and against the hospital?
Queen’s Hospital has admitted liability and Mr De Jesus’s solicitor, Andrew Harrison, of Sternberg Reed, whom Mr De Jesus says has gone ‘above and beyond the call of duty’ for the family, is negotiating a compensation settlement.
Mr Harrison says no fewer than eight members of staff at the hospital are under investigation by the General Medical Council, their cases pending.
Mr De Jesus is upset with the way the hospital has dealt with the tragedy. Some seven months after his wife’s death, he received a copy of the hospital’s ‘maternal death investigation’, which failed to answer many of the family’s questions. ‘Nobody has ever come to this house to talk to us and say sorry,’ he says. ‘We finally got a letter of apology last Saturday, after the inquest ended.’
In a statement, Averil Dongworth, chief executive of Barking, Havering and Redbridge Hospitals Trust, said: ‘I would once again like to apologise unreservedly to Mrs De Jesus’ family for their loss.
‘The staff involved in Mrs De Jesus’ care have been deeply affected by her death.
‘An extensive Trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again.’
No amount of compensation will lessen the family’s anguish at Maria death, and the way she died.
‘If she’d fallen ill and died then we would be devastated but would have to accept it,’ says Ms Caldeira.
‘But this, we can never come to terms with. Watching my sister suffer in those last few weeks, I cannot explain how I feel about it.
‘Hospitals are there to save lives. In Maria Joao’s case, all they did was prolong her death.’
This article is courtesy of the Daily Mail.
But Maria’s death, the manner of it, makes no sense at all. Admitted to hospital at five months’ pregnant with severe abdominal pains, she was told she had appendicitis and needed her appendix removed.
Why, her grieving husband and three children ask themselves, were two trainee surgeons permitted to carry out the procedure without a consultant present? And how on earth did they manage to mistake her ovary for the appendix and remove the wrong organ?
Why, when it was established in a laboratory that the organ was not an appendix at all, did the lab technicians not bother to notify anyone of this fact?
Why did they log the details of this catastrophic mistake on to a computer, as though it were a routine report, and forget about it? Why did the person who commissioned the report never bother to seek out the results? From the day she was admitted on October 21, 2011, until her death three weeks later on November 11, Mrs De Jesus remained in severe pain and was in and out of intensive care.
Yet it was not until two days before her death that a consultant finally looked at her notes and stared in disbelief at the laboratory report stating there was ‘no appendix tissue’ present.
But by then it was too late. Mrs De Jesus had sepsis and, after suffering a miscarriage, died on the operating table hours later during a second operation to remove the appendix.
She was just 32, a beautiful mother-of-three who had been excitedly awaiting the birth of her fourth child.
Last week, Mrs De Jesus’s husband, Adelino, listened to the harrowing details of his wife’s last weeks at her inquest in East London. He remains shell-shocked. Mr and Mrs De Jesus’s sons Pedro, nearly 17, and Andre, who has just turned 16, are full of anger. Their ten-year-old sister Catarina, who has inherited her mother’s beauty, has retreated into herself.
My wife didn’t stand a chance,’ says Mr De Jesus. ‘She spent the last three weeks of her life in agony. She was beautiful, full of life, a wonderful mother. I can’t believe what they did to her. She was treated like an animal. I believe she was unlawfully killed.’
The details of Maria De Jesus’s mistreatment at Queen’s Hospital in Romford, Essex, are truly shocking.
Neglect, disregard for protocols, incompetence, a total absence of inter-departmental communication. Everything that could go wrong, did go wrong.
Her family want the full story told because they believe the medical staff responsible for the catastrophic errors that led to her death should be held accountable.
Originally from Funchal on the Portuguese island of Madeira, Mr and Mrs De Jesus married in 1996 and moved to England in 2005 to seek a better life for their family. The recession in Portugal had hit them badly. Mrs De Jesus’s full name was Maria Joao; in England she became known as Maria.
Initially, the couple found work with a family in South London, with Maria working as a nanny and her husband doing chauffeuring.
But living in London was expensive and, in 2007, the family moved to a spacious house in Becontree, Essex, and Maria started work as a teaching assistant at a local school.
On Friday, October 21, 2011, and five months’ pregnant, Mrs De Jesus began feeling unwell at work. Her husband took her to a walk-in centre, where she was told she needed hospital treatment.
On arrival at Queen’s Hospital in Romford, Essex, she was admitted. ‘There was uncertainty as to what was wrong,’ recalls Mr De Jesus.
‘The next day, the doctors said they needed to operate on her kidneys, then, the day after that, on the Sunday, they said they needed to take her appendix out.’
Mr De Jesus and his wife’s sister, Ana Caldeira, were at the hospital with Maria before she went into theatre.
‘We were told it would be a 30-minute procedure,’ recalls Ms Caldeira, a 35-year-old teacher at a special needs school and mother-of-two.
‘But Maria Joao went in at 3pm and didn’t come out till 6pm and was taken straight to intensive care.
We had no idea the operation was being done by trainee surgeons, without a consultant present.
When we later found this out we were profoundly shocked and disbelieving.
‘One of the consultants said he needed to talk to us. He said he’d been called in during the middle of the operation because the other surgeons had cut her uterus accidentally and they needed to stop the bleed. The blood loss meant she also needed a blood transfusion.’
Mrs De Jesus spent the next eight days between intensive care and the maternity ward. ‘She felt very unwell,’ says Mr De Jesus. ‘She was vomiting, her heartbeat was up, she was heavily medicated on painkillers.’
But Mrs De Jesus was declared fit to be discharged on October 31. On the same day, the results of the tests on the organ that had been removed were put onto a computer system accessible to hospital staff.
But in fact, the inquest heard, laboratory staff had first become aware the organ was not an appendix about four days before that, around October 27.
‘I just can’t understand how nobody said anything,’ says Mr De Jesus. ‘It seems incredible to me.’ If someone had been notified, Mrs De Jesus might have been saved. As the coroner at Mrs De Jesus’s inquest recorded in his narrative verdict: ‘The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.’
Mrs De Jesus spent the next eight days between intensive care and the maternity ward. ‘She felt very unwell,’ says Mr De Jesus. ‘She was vomiting, her heartbeat was up, she was heavily medicated on painkillers.’
But Mrs De Jesus was declared fit to be discharged on October 31. On the same day, the results of the tests on the organ that had been removed were put onto a computer system accessible to hospital staff.
But in fact, the inquest heard, laboratory staff had first become aware the organ was not an appendix about four days before that, around October 27.
‘I just can’t understand how nobody said anything,’ says Mr De Jesus. ‘It seems incredible to me.’ If someone had been notified, Mrs De Jesus might have been saved. As the coroner at Mrs De Jesus’s inquest recorded in his narrative verdict: ‘The absence of protocols for reporting adverse histopathological findings resulted in the loss of a window of opportunity to provide treatment to the deceased that could have affected the outcome.’
Ms Caldeira adds: ‘We still don’t know why a consultant wasn’t present at the original operation. I think those two trainee surgeons who operated on her were arrogant, they thought they could do it by themselves.’
That day, Mrs De Jesus underwent the drainage procedure. It seemed to go well, but at midnight that night, Mr De Jesus took a call from the hospital saying to come to the hospital immediately.
He and Maria’s sister, who was staying at the house, made a frantic dash by car and when they arrived, were told that Maria was miscarrying. ‘She was moaning and crying and shaking,’ says Ms Caldeira. ‘I begged them to do a Caesarean but they refused.’
Mr De Jesus recalls the moment his baby son was born. ‘I held him and I felt that he was moving, that he was alive, but then the staff took him away from me and told me he was dead, that he had been stillborn.’
Maria, Ana, and Adelino were left alone for 45 minutes while staff dealt with another emergency.
‘Maria began to deteriorate during this time,’ says Mr De Jesus. ‘There was blood everywhere, her oxygen levels were low, her eyes were closed, she was gasping for breath. Suddenly lots of people were coming in and out.
‘The senior consultant came back and said they had a feeling Maria had septicaemia and they had to do something about it.’
Ms Caldeira goes on: ‘I asked one of the surgeons if Maria could die and he replied no, there was no life risk. The only thing that might happen was that they would have to remove the uterus.’
There followed an awful scene in which, Ms Caldeira says, the medical team were shouting at her sister to sign the consent form, when she was clearly in no fit state to do so. ‘I kept saying, let her husband sign, but they wouldn’t listen. I don’t know why, perhaps because Adelino doesn’t speak very good English.
‘Eventually I forced a pen between her finger and said: “If you don’t sign the form, you’ll die,” and she scribbled something down. We said goodbye to her as she was taken down to theatre. She was semi-conscious.’
Mr De Jesus and Ms Caldeira drove home to check on the children, but at 8am there was another phone call from the hospital, requesting that Mr De Jesus return immediately.
‘I said to Ana: “Oh my God, something bad has happened”, but Ana tried to reassure me that the operation had not gone as well as it should have, that it was no worse than that.’
But Ana, too, had a feeling about it and as soon as she and Mr De Jesus were shown into a room she said: ‘Just tell me, is she alive or dead?’ ‘The consultant replied: “I’m so sorry, she passed away”,’ recalls Ms Caldeira.
‘Adelino was so distraught he started having chest pains and had to be put in a bed. The doctors later explained that the operation had gone well, her heartbeat was fine, and they had removed the appendix, which had a pelvic abscess around it.
‘Then suddenly without warning she went. She had gone into cardiac arrest. They tried everything to bring her back but her septicaemia was so advanced it had caused all her major organs to shut down.’
Mr De Jesus and Ana returned home and Ana went upstairs while the children’s father told them their mother was dead.
‘I don’t want to talk about that moment,’ says Mr De Jesus. ‘All I will say is that they were all very insistent that they wanted to see her.
‘I took them to her and she was all swollen and looked nothing like herself. It offered them no comfort whatsoever — quite the contrary.’
The loss of Maria has, of course, devastated the family. Adelino, who faces no prospect of being able to work with three children to look after, is desolate and visits her grave every day.
‘Maria Joao was the heart of our family,’ he says. ‘She was so beautiful and fun-loving and did things with the kids like white water rafting. Easter and Christmas and birthdays were big occasions for us and Maria would cook and organise everything.
‘The three children must go through life without a mother. Pedro and Andre feel very angry at her treatment.
‘Catarina will go through her teenage years, getting married, having children, without her mother. She was her mother’s girl. We will never get over this. She is irreplaceable.’
There remains a lot of anger. ‘No one was leading Maria Joao’s case, no one was in charge,’ says Ms Caldeira. ‘It was being handed over, passed around. There was no communication, no organisation.
‘The treatment by some of those doctors was appalling, but amid all the bad there was good as well, good doctors, who did their best. But it was too late.’
Maria’s son, Pedro, says simply: ‘All those who contributed to my mother’s death should be jailed.’
So what, if any, action will be taken against these members of staff, and against the hospital?
Queen’s Hospital has admitted liability and Mr De Jesus’s solicitor, Andrew Harrison, of Sternberg Reed, whom Mr De Jesus says has gone ‘above and beyond the call of duty’ for the family, is negotiating a compensation settlement.
Mr Harrison says no fewer than eight members of staff at the hospital are under investigation by the General Medical Council, their cases pending.
Mr De Jesus is upset with the way the hospital has dealt with the tragedy. Some seven months after his wife’s death, he received a copy of the hospital’s ‘maternal death investigation’, which failed to answer many of the family’s questions. ‘Nobody has ever come to this house to talk to us and say sorry,’ he says. ‘We finally got a letter of apology last Saturday, after the inquest ended.’
In a statement, Averil Dongworth, chief executive of Barking, Havering and Redbridge Hospitals Trust, said: ‘I would once again like to apologise unreservedly to Mrs De Jesus’ family for their loss.
‘The staff involved in Mrs De Jesus’ care have been deeply affected by her death.
‘An extensive Trust-wide action plan was drawn up following Mrs De Jesus’ death in 2011 to ensure that such a tragic incident will not happen again.’
No amount of compensation will lessen the family’s anguish at Maria death, and the way she died.
‘If she’d fallen ill and died then we would be devastated but would have to accept it,’ says Ms Caldeira.
‘But this, we can never come to terms with. Watching my sister suffer in those last few weeks, I cannot explain how I feel about it.
‘Hospitals are there to save lives. In Maria Joao’s case, all they did was prolong her death.’
This article is courtesy of the Daily Mail.
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