Deaths foretold

In March 2010, Caitlyn Parry came to Alder Hey (AH) to have a simple kidney tumour removed. She should have had an excellent prognosis.

She died without ever regaining consciousness, after her surgeon cut the wrong arteries. This fatally deprived her liver and intestines of their vital blood supply. The surgeon then failed to recognise this in time for her life to be saved. Her mother tells of her own seven-year fight to uncover the truth here.

This death cannot be dismissed as a simple accident.

Vascular exposure
Major abdominal arteries should be safely identified like this, before any are cut

Caitlyn’s surgeon had just returned from extended leave of up to a year due to workplace bullying. Bullying is a safety risk, of which I’d warned in 2007 and 2009. Campaigns to address this systemic hazard have since been launched by The Royal Australian College of Surgeons and the Royal College of Surgeons of Edinburgh.

Caitlyn’s consultant had not performed this type of tumour surgery in over a year. Remarkably, he was left unsupervised with her case on his return. One would normally have expected another consultant to carefully oversee her surgery.

A 2010 report into the surgical division by Dr Alan Phillips, the hospital psychologist, confirmed that back-to-work safety checks weren’t being done properly or at all. The hospital spent over £50,000 seeking to prevent his report’s release under the Freedom of Information Act. It wasn’t disclosed to the Royal College of Surgeons (RCS) investigators in this case. Their 2011 report on the death was also redacted by the Trust and the RCS has refused its release also.

The hospital’s primary reports to the Coroner made no mention of these systemic problems. Nor was it mentioned that I’d forewarned against these issues, just months before her death.

Before being seconded to the USA in February 2010, I was responsible for major tumour surgery. I had met on several occasions with Caitlyn’s eventual surgeon and had advised that he seek support if he returned to performing such operations. I followed this up in a meeting with Alder Hey’s Medical Director (MD) and Clinical Director. Given the surgeon’s potential return, it was agreed in writing that a lone consultant model would be avoided for major tumour surgery. The MD instructed the Clinical Directors (old and new) to put governance arrangements in place to ensure this. We’ve never been told why this wasn’t done.

Had these governance arrangements been in place, Caitlyn’s surgeon would not have been left unsupervised and his fatal error would almost certainly have been avoided. Like amputating the wrong limb, cutting the wrong arteries in these circumstances amounts to a “never event”.

I reported that this was no simple accident, but a failure of process. Alder Hey responded to Parliament and others that all my concerns had been repeatedly investigated and found each time to be “completely without foundation” and proven “absolutely untrue”.

What should be done now?

Alder Hey was forewarned, but it failed to protect Caitlyn. It then seriously misled Parliament on this matter.

Alder Hey’s lack of honesty to Parliament and its incomplete reports to the Coroner mean her death should be treated like those of  Connor Sparrowhawk and Teresa Colvin at Southern Health. The Health and Safety Executive should investigate Alder Hey, so the issue can be resolved and UK-wide reforms put in place to prevent repetition.

Footnote: This case illustrates the injustice in the case of Jack Adcock and Dr Hadiza Bawa Garba. Unlike the latter doctor, Caitlyn’s surgeon and the Clinical Directors responsible have not been named in the press, prosecuted or struck off by the General Medical Council. Rather, the Clinical Directors have removed Mr Ahmed and me.