Nottingham University Hospitals NHS Trust (NUH) has paid damages to three families whose relatives died after undergoing the same specialised endoscopy procedure. The BBC reported that the patients died after a procedure called an endoscopic retrograde cholangiopancreatography (ERCP) at the NHS trust.
William Doleman, 76, Anita Burkey, 85, Peter Sellars, 72, and Carol Cole, 53, died in the space of about six months following complications after undergoing the procedure - where a tube is passed through a patient's throat to examine and treat possible gallstones and other conditions. The surgeries were all carried out by the same doctor but the coroner concluded it was the systems in place to properly gain consent and inform patients of the risks of the procedures that were the issue, not the doctor's competence.
NUH had considered all four deaths were unavoidable, Nottingham's Coroners' Court was told in December. But Laurinda Bower, assistant coroner for Nottinghamshire, found this was not the case and she issued a prevention of future deaths report.
She was concerned by the lack of a formal action plan for change. One doctor, who assisted the inquest with his opinion, said there should have been a personalised approach regarding the patients who underwent the procedure, some with existing medical problems which had not been flagged up. The coroner said the personal approach was "what was missing in all these four cases".
The families have now accepted undisclosed damages from NUH over the deaths. The trust's deputy medical director John Walsh said: "We would like to offer our sincerest condolences to the families for their loss and we are 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 taken other actions to manage these complex, high-risk cases.
"We have made significant changes including appointing more consultants who can deliver lower risk endoscopy to ensure this procedure is still required, introducing an extra clinic where families can be involved in the discussion of benefits and estimated personalised risk, and we are developing advanced real-time data analysis to track outcomes and inform our consent conversations.” NUH said its ERCP endoscopy service now performs amongst the highest numbers of procedures nationally.