Wednesday, February 22, 2012

Crown Office are staying quiet about possible prosecutions after an inquiry found medical failures caused three deaths at NHS Lanarkshire.

In response to a specific question as to the possibility of prosecutions, a Crown Office spokesperson told Wikinews today that “The three deaths were fully investigated by the Procurator Fiscal and reported to Crown Counsel [laywers] to consider. Crown Counsel concluded that, given the facts and circumstances of the deaths, a Fatal Accident Inquiry (FAI) was the appropriate forum to consider the circumstances of the deaths.” It was further noted that “[a] FAI cannot make any findings of fault/blame against individuals.”

However, Crown Office did not specifically rule out prosecutions for offences such as cuplable homicide despite the spokesperson noting this was a direct response to such a question. They also declined to comment on National Health Service care as “it would not be appropriate to comment on the provision of NHS services” and entirely ignored questions about Crown Office satisfaction in the inquiry’s outcome and the length of time it took to reach a conclusion. The inquiry wrapped up last week but the deaths were in 2006.

Agnes Nicol, George Johnstone, and Andrew Ritchie died within a three-month period following keyhole surgery to remove their gall bladders.

Later expanded to look at all three deaths, the inquiry initially established to look into the case of Nicol, 50, who received surgery in late 2005. A surgeon at Wishaw General Hospital mistakenly cut her bile duct and her right hepatic artery. Whilst suturing her portal vein, her liver was left with 20% of its normal blood supply; the errors were not discovered until her transfer to liver specialists at Edinburgh’s Royal Infirmary.

By then, her liver was seriously damaged. She developed septicaemia, dying from multiple organ failure in March 2006.

Johnstone, 54, underwent the same procedure at Monklands District General Hospital on May 9, 2006. A consultant surgeon accidentally damaged, possibly severing, his bile duct. He died two days later in intensive care from the combined effects of multiple organ failure and a heart ailment.

Ritchie, 62, died in intensive care a week after an operation in June 2006. He died from intra abdominal haemorrhage caused by errors during the surgery.

Different surgeons were involved each time and the inquiry, under Sheriff Robert Dickson, found no evidence of poor training or inadequate experience. Dickson noted that in each case there was lack of action on a “growing body of evidence that there was something fundamentally wrong with the patient” and surgeons failed to contemplate their own actions as potentially responsible. He agreed with two professors that it may have been possible to save their lives “had the post-operative care been to the standard which they expected, and had there been a proper management plan which staff could have worked to” and noted that all the patients suffered from a lack of adequate medical notes being available after their surgery. He described the care as having “clear faults”.

NHS Lanarkshire apologised and said improvements had been made regarding “these types of cases” as well as with document management. Wikinews got in touch seeking details of the changes made but the health trust failed to respond.