Coroner slams NHS Trust after TEN cancer patients died following experimental treatment

A coroner has slammed failings at an NHS Trust after ten cancer patients died after undergoing experimental treatment by a consultant.

Paul Miller, 62, a consultant urologist, worked at East Surrey Hospital in Redhill treated patients suffering from bladder and prostate cancer.

But instead of pursuing traditional therapies he sent patients for High Intensity Focused Ultrasound (HIFU) which uses high frequency sound waves to burn away cancer cells.

At the time HIFU was an ‘experimental’ treatment not recommended by National Institute of Health and Care Excellence (NICE) and could only be used as part of a clinical trial.

However Mr Miller would routinely refer his patients for treatment at the private Spire Gatwick Park Hospital, where he also worked and co-owned a £500,000 HIFU machine.

Between 2006-2014 ten cancer patients died after they were treated by the consultant urologist. 

Renfried Avery died aged 80, pictured with his wife Doreen. Mr Avery’s only child Mark, 44, said after seven years he finally feels he has ‘some answers’. However Mrs Avery passed away almost two years ago and did not live to hear the outcome

Coroner Penelope Schofield ruled that seven patients died from natural causes but said that Renfried Avery, 80, Leslie Owers, 75, and Graham Stoten, 57, all died of natural causes contributed to by neglect.

At an inquest into the ten deaths today, West Sussex Coroner Penelope Schofield condemned Surrey and Sussex Healthcare NHS Trust (SASH) for failing ensure patients received proper care.

She said the clinical treatment of patients was ‘suboptimal’ and there were ‘missed opportunities’ to cure or extend the lives of patients.

The inquest in Crawley, West Sussex was told the three-man team of consultants did not work well as a team and it often felt like they were involved in a ‘guerrilla warfare.’

Miss Schofield said senior management failed to respond to serious concerns about Mr Miller’s treatment of patients.

Renfried Avery was one of three patients who died of natural causes contributed to by neglect, the coroner ruled 

‘Senior managers were aware of the risk of safety of patients yet they took no action,’ she added. 

Miss Schofield said there was ‘no real appetite’ to follow through the allegations of Mr Miller and he was able to carry on working ‘unhindered’ because of the Trust’s lack of procedure to deal with staff complaints. 

She said decision-making at senior levels seemed more geared to protecting the Trust reputation.

The inquest heard senior colleagues and nurses became extremely concerned about a major conflict of interest.

They felt patients whose conditions would not benefit from HIFU were being referred to the private hospital for treatment on the £500,000 machine.

Whistleblowers raised the alarm and reported the consultant to senior management at SASH but were dismayed and frustrated when nothing was done.

Professor Adhay Rane, a consultant urologist and colleague, told the inquest in Crawley, West Sussex, he approached the hospital clinical director, Raj Siva, at least four times to voice concerns over Mr Miller’s treatment of patients.

The ten patients who died were aged between 57 and 86 including Frederick Le Vallois, 71, Keith Reynolds, 68, Alan Burgess,72, Leslie Owers, 75, Ian Spurgeon, 85, Lilian Cole, 82, Jose Cressy, 76, Graham Stoten, 57, Renfried Avery, 80, and Martin Turner, 86.    

Bladder cancer patient Graham Stoten, who died aged 57, pictured with his two sons died of natural causes contributed to by neglect, the coroner ruled 

Bosses at SASH took five years to act on concerns of staff but eventually Mr Miller was suspended and an investigation was launched.

On conclusion of the review in 2014 the Trust sacked the consultant from his £130,000-a year job.

The Trust then wrote a letter to more than 1,200 patients treated by the consultant asking if they had concerns about their care.

The Royal College of Surgeons launched its own investigation and found that 27 cancer patients treated by Mr Miller had suffered ‘serious harm’ at the hands of the consultant.

A General Medical Council hearing later ended with restrictions being placed on him treating cancer patients.

In a statement released after the inquest Mr Avery’s only child Mark, 44, said: ‘It has been seven years since my dad passed away and I finally feel as if we have got some answers. It’s just a shame my mum, who died almost two years ago, isn’t here to see it.

‘She was by my dad’s side through every step of his illness and was taken in by Miller as well. He was the expert and they trusted him implicitly – they put dad’s life in his hands.

‘It is devastating to think that with different treatment we could have had months or even years left with him and that’s something I will never be able to forgive Miller for.

‘Personally I have also found it very upsetting to hear the trust’s attempts to wriggle out of all responsibility when there were clearly failings on their part. Rather than admit their mistakes, they seemed more concerned with protecting their own reputation.

The inquest at Crawley Corner’s Court in West Sussex was told the three-man team of consultants did not work well as a team and it often felt like they were involved in a ‘guerrilla warfare’ 

‘My dad was one of the first people to raise concerns about Miller and my parents were always determined to get to the truth and make sure the same didn’t happen to anyone else.’ 

He added the real issue for his mother Doreen Avery was that Mr Miller ‘seemed to show no remorse for his actions’ after moving to America to continue practising. 

‘Hopefully now he will finally be held accountable for his actions,’ he added. 

Clinical negligence lawyer acting for Mark Avery, Victoria Beel, said Mr Miller ‘gambled with the precious time’ of his patients and ‘has shown no remorse for his actions’. 

Mr Miller was sacked by East Surrey Hospital in Redhill in 2014 from his £130,000-a-year job 

Ms Beel added: ‘Dr Miller abused his position of trust and showed total contempt for his patients, making decisions that would seriously affect their lives without their knowledge or consent.

‘He gambled with the precious time they had left and even now has shown no remorse for his actions, all of which continues to raise serious questions about his fitness to practice.

‘While the General Medical Council will now investigate this, it is imperative that the trust also learns from its own failures to stop Dr Miller earlier and ensures there are robust and rigorous systems in place to prevent this from ever happening again.’

Dr Ed Cetti, medical director at SASH, said: ‘We extend our sympathies and sincere apologies to the family and friends of all those involved. We are sorry that historic poor practice led to some patients not receiving the standard of care they were entitled to expect.

‘In the years since this period, we have worked hard to create the environment, systems and processes that ensure staff are supported to raise concerns, and that lessons are learnt and improvements made as a result. The culture of our organisation has been transformed, with the independent regulator rating us outstanding earlier this year.’