FAI into the deaths of Agnes Nicol, George Johnstone & Andrew Ritchie

Summary of the Fatal Accident Inquiry Determination issued by Sheriff Dickson

A Fatal Accident Inquiry into the death of Mrs Agnes Nicol was held at Cumbernauld between 24th October and 16th November 2011.  At the same time the Inquiry was asked to consider evidence in relation to the deaths of Mr George Johnstone and Mr Andrew Ritchie. 

On 23rd November 2010 the Procurator Fiscal at Airdrie, on behalf of the Lord Advocate, petitioned the Court to hold this joint inquiry in terms of Section 1(1)(b) of the Fatal Accident and Sudden Deaths Inquiry (Scotland) Act 1976.  It was considered to be in the public interest to hold an inquiry into three deaths which had occurred in a three month period in 2006 following, in each case, a laparoscopic cholecystectomy (keyhole gallbladder removal) in a Lanarkshire hospital.  The evidence established that cholecystectomies are one of the most common operations carried out and there was natural concern when on three separate occasions patients died following such an operation.

Agnes Nicol died within Ward 118 Intensive Therapy Unit, Edinburgh Royal Infirmary at 12:57pm on 10th March 2006.  The cause of death was multiple organ failure due to recurrent septicaemia due to hepatic infarction due to complications of endoscopic chlolecystectomy carried out on 22nd December within Wishaw General Hospital.  The complications were caused by a misidentification of the anatomy by a Staff Grade Surgeon who wrongly cut the common bile duct and right hepatic artery and the subsequent suturing of the portal vein by a Consultant Surgeon cutting off 80% of the blood supply to the liver. (see paras 16 and17) These mistakes were not discovered until Mrs Nicol was transferred to the Liver Unit at Edinburgh Royal Infirmary.

No attempt was made at Wishaw Genera Hospital to investigate why she was deteriorating and the Consultant did not record anything in the medical notes. He ignored the exceptionally high ALT figures (Para 24) which showed a major liver problem until the evening of 28th December. By the time Mrs Nicol was sent to Edinburgh her liver was so badly damaged that she died there.

George Johnstone died within the intensive care unit, Monklands District General Hospital, Airdrie at 7:55pm on 11th May 2006.  The cause of death was multiple organ failure due to a biliary leak following laparoscopic cholecystectomy carried out on 9th May 2006 within Monklands District General Hospital by a Consultant General Surgeon and that a secondary cause was ischemic heart disease. The biliary leak arose due to the Consultant either cutting or damaging the main bile duct. (Para 13). The cause of Mr Johnstone’s deteriorating health post operatively was not investigated by the Consultant Surgeon despite a junior doctor specifically querying whether there was an abscess and seeking Consultant advice at 4.30am on 11th May (Paras 28 – 35). He did not return the patient to surgery when a scan at 11 30am showed fluid around the liver and within the pelvis (Para 44) Professor Garden from Edinburgh Royal Infirmary in his evidence stated that, had this been his patient, he would personally have pushed the patient’s bed into the operating theatre to minimise any delay (page 46).

Mr Andrew Ritchie died within the Intensive care unit, Wishaw General Hospital at 3pm on 23 June 2006.  The cause of death was an intra abdominal haemorrhage due to dehiscence of the duodenal surgical site due to a laproscopic cholecystectomy due to chronic cholecystitis. The duodenal perforations occurred during or as a direct result of the surgery carried out by a Consultant General Surgeon on 14 June (para 20). No investigation took place until 20 June to ascertain why there was a continuous discharge of bile from the operation site. Despite the Consultant herself recording the possibility of a duodenal perforation (para 32) on 16th June no scan or operation followed.   

The Inquiry found that there were individual circumstances in relation to each of the deaths and errors made in surgery and in particular the post-operative care of the patients which caused those deaths.  They involved different Consultant Surgeons and there is no evidence that there was a lack of training or experience in the Surgeons involved.

Although the evidence established that the circumstances of each death was different, and the complication which arose in the course of the surgery which led to the patient’s death was different in each case, there are certain factors which are common to at least two if not all of the deaths which require to be commented on.  These are:

• The failure to ensure the filing of all reports within the hospital records.

• The rota system which existed in 2005 (but which has been subsequently changed) whereby a patient admitted as an emergency becomes the responsibility of the consultant on duty on the day of admission.  This was not withstanding the fact that there could be other consultants within the hospital staff who had a greater expertise or experience in the relevant field of surgery. 

• The policy which existed in 2005 that a patient displaying major gall bladder problems on initial admission to the hospital would almost invariably be treated conservatively and expected to return at a later date for an elective operation.

• The failure of the surgeons to consider the possibility that there had been a misidentification of the structures or that structures had been damaged in the course of the operation. This was the cause, or was significantly contributory, to each patient’s failure to recover (pages 39 -40 Andrew Ritchie).

The evidence before the Inquiry showed that at the time the lack of a complete set of records and documents in relation to any of the three patients was indicative of a system which requires to be overhauled. (page 42 Andrew Ritchie)

It is essential that every doctor and nurse responsible for the care of a patient has access to all the records and all the documents and that full notes are available at all times.  In relation to the care of Mrs Nicol, Mr Johnstone and Mr Ritchie this was not so. 

NHS Lanarkshire should ensure in future that there is full documentation recorded by both the doctors and nurses involved in each stage of the treatment of patients, and that the records department ensures that all the hospital records are kept and made available to all those who require access to them. In all 3 cases this had not happened. (pages 40 – 42, Andrew Ritchie)

In his assessment of the records and reports in relation to the three deaths Professor James Garden of Edinburgh Royal Infirmary highlighted three matters. (pages 36 -39, Andrew Ritchie) 

• The management of the initial presentation;

• The management of the post-operative period; and

• The mistaken and apparent unswerving belief of the surgeons that any failure of the patient to respond post-operatively as expected, could not be due to any complication attributable to the operation itself.

Only in relation to the management of Mr Ritchie was this criticism rejected and only in so far as it related to the management of the initial presentation.

Read the full Determination here.