The coroner orders a hospital procedure after four patients died within six months from complications of the same gallstone procedure.
Carol Cole, 53, William Dolman, 76, Anita Burke, 85, and Peter Cellars, 72, died after undergoing an endoscopic cholangiopancreatography (ERCP).
Medical coroner Lorenda Bauer said after a 15-day investigation that it was the systems in Nottingham that led to their deaths, not the technical competence of the trainee who performed the four surgeries.
Power is due to release a report to prevent future deaths calling for action from the NHS Trust of Nottingham University Hospitals after concerns that the four patients were not properly informed of the risks related to the procedure.
The coroner found that Ms. Cole, Mr. Doleman, Ms. Burke and Mr. Sellars died of complications after an endoscopic cardiac procedure – a procedure in which a tube is passed down a patient’s throat to examine and remove potential gallstones from the common bile duct.
Carol Cole, 53, was one of four patients who died after undergoing endoscopic imaging of the pancreas and cholangiopancreatography (ERCP)
Anita Burke, 85, has died after undergoing an endoscopic cholangiopancreatography (ERCP) operation.
The four patients were treated by trainee physician Muthuram Rajaram, but Bauer concluded that it was the ‘existing systems’ that were ‘the systems in place’ to get consent properly and inform patients of the risks related to the procedure that was the problem, not Dr. Rajaram’s technical competence.
The NHS Trust for Nottingham University Hospitals now has 56 days to draw up an action plan after receiving a future death prevention report from the coroner, according to the BBC.
Concluding the investigation, the coroner said: “These cases correctly provided cause for concern when it was determined that all four deaths occurred at the hands of the same intern and within a span of approximately six months.
“But as the evidence crystallizes during the investigation, it appears that the issues relate to the systems at Nottingham rather than the technical competence of Dr Rajaram.”
The coroner found that William Dolman, 76 (left) and Peter Sellars, 72 (right) also died from complications after having an emergency heart exam.
The investigation heard that Mr. Doleman should not have undergone ERCP, Mr. Sellars and Ms. Cole were not informed of the individual risks, while Ms. Berkey was not adequately counseled.
Ms Cole, of Prosto, died of an aggressive form of pancreatitis at Queen’s University Medical Hospital, and Power ruled her death “abnormal”.
The mother of two was diagnosed with gallstones last year after experiencing abdominal pain, which led to her undergoing ERCP.
But after returning home after the procedure, Ms Cole described feeling ‘a tear inside’ and said she was ‘in pain’.
She was hospitalized with pancreatitis and placed in intensive care, but later died.
Ms Cole, of Prosto, died of an aggressive form of pancreatitis at Queen’s University Medical Hospital, and Power ruled her death ‘abnormal’
‘Our whole family has been devastated by having to adjust to life without Carol,’ said Trevor Cole, who has been married to his wife Carol for more than 20 years.
Neither of us was ready for it after the procedure was just a simple chore and I had no idea she was ok that evening.
I was shocked when I was told that Carol was gone and I don’t remember much after that other than having to pass the news on to our two sons, Ashley and Mitchell. It was one of the hardest things I had to do.
It was taken from us too soon and everyone who knew it will miss it. For me, it was perfect and I will never forget it.
Addressing the families, the coroner said: ‘I can’t imagine how difficult it would be for all of you to lose a loved one in these circumstances.
I hope that over time, you will feel some comfort from the fact that it is certainly my intent that some learning can come from these deaths so that the safety of this high-risk procedure continues to improve, that understanding the personal risks and discussing those risks with patients becomes a standard part of the path, and it will be This is the legacy of Bill, Anita, Peter and Carol.
Philip McGough, of Freeths Solicitors, which has represented the families of Mr Sellars, Mrs Burkey and Mr Doleman, told the BBC: Our clients have been acquitted of believing that many things have gone wrong here to varying degrees and there are many questions that need to be answered.
“[They’re] Sad because based on what we’ve heard over the past three weeks in the coroner’s court, much of what happened could have been avoided.
“We can only hope that the lessons learned here will be applied by the hospital’s confidence in the future.”
John Walsh, Deputy Medical Director at the NHS Trust University Hospitals Nottingham, said: ‘we would like to We offer our sincerest condolences to the families on their loss and truly sorry for any shortcomings in the care we provided.
Although each case is unique, we should have done more to involve families in decisions about patient care as well as take other actions to manage these complex, high-risk cases.
We’ve made significant changes to a number of our policies and processes in these areas, including a review and changes to when and how a serious accident is declared, to ensure patients undergoing ERCP receive the appropriate and timely care they need.”