A woman died after a senior consultant overruled the doctor who raised concerns during a fairly routine operation, an inquest heard.
At the close of a hearing at Ruthin, Nicola Jones, assistant coroner for North Wales East and Central, said she was considering issuing a warning to all health boards in England and Wales about Peter Sullivan, but after hearing that he had now relinquished his registration to practice in the UK she said she need not issue a Regulation 28 letter to prevent future deaths.
Mr Sullivan, a consultant obstetrician and gynaecologist, is inFrance and had been summoned to give evidence at the inquest into the death of 69-year-old Barbara Annette Aldridge, of Flint.
He was not present and Mrs Jones told Mrs Aldridge’s son Ian: ‘I cannot compel him to attend.’
Mr Alridge described the consultant’s non-appearance as ‘cowardly’.
The inquest heard that Mrs Aldridge, of Third Avenue, Flint, – the wife of Flintshire County councillor Alex Aldridge – was admitted to Glan Clwyd Hospital in March, 2016, and underwent surgery for the removal of two polyps on her uterus.
After one polyp had been removed the hysteroscope, an illuminated camera used to assist, came apart and though Dr Arumugam Jayanthi, a locum at the hospital, suggested that it be removed from inside Mrs Aldridge for it to be reconnected, he insisted that it be done in situ.
Former lady mayoress Annette Aldridge, 69, died after surgeon Peter Sullivan tried to fix a medical instrument that broke during an operation – while it was still inside her body
‘Cause of death was multiple organ failure due to internal trauma’
Before the second polyp was removed Dr Jayanthi told him ‘something is not right here’ but he carried on.
The doctor told the inquest she was aware of the risk involved and it later transpired that the uterus was perforated and damage was also caused to her bowel.
When Dr Jayanthi subsequently raised concerns about Mrs Aldridge’s recovery Mr Sullivan dismissed them too.
Mrs Aldridge’s condition deteriorated and she suffered further bleeding later in the year before she died in hospital in January this year. Home Office pathologist Dr Brian Rodgers said the cause of death was multiple organ failure due to internal trauma.
He said: ‘She would not have died when she did had she not had the hysteroscopy which went wrong.’
Dr Jayanthi told the inquest that Mr Sullivan had overruled her once before and done the same with other colleagues. On one occasion he told a nurse to ignore Dr Jayanthi, adding: ‘I’m the boss’.
She said other consultants would probably have listened to her concerns but she felt unable to challenge him.
Ms Aldridge later died of multiple organ failure due to internal trauma (stock)
‘It’s too little, too late’
Mrs Heledd Jones, head of women’s in-patient services, said independent experts had been called in to investigate the case before Mrs Aldridge died and had identified several issues including a failure to recognise the way her condition had deteriorated.
She said an action plan had been introduced under which anyone, including nurses and doctors, who had ongoing concerns had to take them higher than their own direct superiors. Failure to do so could now lead to disciplinary action.
Monitoring and record-keeping is also to be tightened up. Ian Aldridge said he accepted Dr Janynthi’s apology and welcomed the changes, but added: ‘It’s too little, too late so far as I am concerned.’
The Assistant Coroner recorded a narrative conclusion in which she stated that the uterus was perforated during surgery.
‘This was not appropriately and effectively diagnosed and caused her death,’she added.
She said it would be very unusual to issue a Regulation 28 letter naming an individual but she had a responsibility to prevent future deaths.
After initially agreeing to postpone a decision on the matter to ascertain whether Mr Sullivan could return to work in the UK she learned that his registration had been relinquished.
After the hearing a spokesman for the Betsi Cadwaladr University Health Board said: ‘This is a rare and tragic case and we would like to apologise to the family of Mrs Aldridge for the failings in the care she received. We fully accept the Coroner’s verdict and have already made improvements to minimise the risk of this happening again.’