Within six months of each other, after receiving the same gallstone procedure, four patients died and action has been demanded by a coroner to prevent further deaths.
Following a 15-day inquest it was seen that the system that was in place led to their deaths, rather than the technical competence of a trainee doctor who carried out the surgeries.
Nottingham University Hospitals NHS Trust is set to be issued with a “Prevention of future deaths” report following concerns that the four patients were not properly informed about the risks of the procedure they were to undergo. This involved passing a tube down a patient's throat to examine and remove possible gallstones.
The Nottingham University Hospitals NHS Trust now has 56 days to create an action plan having received the report from the coroner. The Trust are said to have already made significant changes to their policies and processes.
Medical lawyer Stuart Bramley observes -
"Most medical negligence claims and healthcare-related inquests focus on alleged errors by individuals but as this sad story illustrates, patients can be injured or worse by systemic failures as well. Recently I represented a couple whose baby died when the mother was found to be carrying a potentially fatal infection but when the GP surgery wrote to her at an old address about this and received no response, they followed their own system and took no further action.
I am pleased the Nottingham Coroner has called for changes here. Patients undergoing a relatively commonplace and straightforward procedure should not die as a result; why were four allowed to die before it was recognised that they all had something in common? I sincerely hope that all necessary changes are effected in the Trust involved - the people of Nottingham deserve nothing less."
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