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Hospital probe after three deaths
Coroner orders ‘review’ into UCLH procedures to prevent further fatalities
A CORONER has ordered a review of procedures at University College London Hospital after an inquest was told how three patients died following surgery.
Tracey-Ann Korkmaz, 41, from Fulham, Jack Brown, 76, from Enfield and Karen Blakey, 44, who lived in De Beauvoir Town, Islington, all died after suffering fatal injuries to their internal organs during non-emergency operations this year.
On Tuesday, St Pancras coroner Dr Andrew Reid ruled that they had died as a result of “accidental adverse healthcare events”.
He used his strongest powers to make recommendations to Camden Primary Care Trust, The National Patient Agency and the National Clinical Assessment Agency.
Dr Reid said: “I do not do this lightly. I understand that such a report may well be distressing to those involved in their care and obviously to the families of the patients concerned. However, I have concluded that the prevention of similar fatalities of others will be assisted by getting a report to the appropriate authorities so that further examinary reviews of the surgical incident or incidents concerned in these cases can occur.”
In all three cases, surgeons had to carry out unplanned removals of organs after complications arose during surgery.
Although Dr Reid was shown the UCLH’s own internal review of the cases, he ordered further inquiries.
He said: “Those who perform services at the UCH and those who look at adverse incidents and fatality issues need to look at these causes and conduct examinary reviews to supplement others already going on at the Trust.”
Ms Blakey, who worked for a modelling agency, died in June, months after complications arose during an operation to remove a pancreatic tumour. Her pancreas was damaged and her small and lower intestine were removed.
Mr Brown lost two litres of blood during a procedure to remove a tumour from his throat. His spleen had to be removed to avoid his heart flooding with blood. A pathologist ruled his coronary vein was fatally torn by a needle inserted to prevent his heart from flooding.
Mr Brown died on the operating table on May 9.
Mother of three, Ms Korkmaz, who weighed 23 stone, was booked in for a gastric bypass to solve her weight problems. She died a week after the operation from blood poisoning, shock and multi-organ failure after her stomach lining was perforated.
Her adopted sister Mandy Norwood said: “All I know is that Tracey went in healthy and never came out. At the end of the day you have three kids without a mum, so something’s not right.”
The UCLH Trust is one of the best performing in the country in terms of its mortality rates.
A UCH spokesman yesterday: “Surgery is a potentially dangerous activity and UCLH carries out a high percentage of complicated cases due to the specialist nature of its services.
“The trust has every confidence in its audit and review processes that ensure that the risks of surgery are kept to a minimum.”
The trust, he said, conducts internal audits on physicians and surgeons every month.
The spokesman added: “The three cases recently heard by the coroner will be considered by the Trust’s Quality and Safety Committee and kept under continuous review to ensure the highest standards are maintained.” |
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