THE death of a Newport man, following surgery to remove liver tumours, is among eight deemed “avoidable” following an independent review of more than 30 operations by a surgeon at a Cardiff hospital.

Martyn Rogers, 66, was operated on in July last year, at the University Hospital of Wales, but died a week later of septic shock and pneumonia, after developing acute liver failure.

His partner of 40 years, Maria Davies, is now demanding answers about what went wrong.

The General Medical Council confirmed it is investigating Mr Rogers’ surgeon David Paul Berry, whose registration has, since March, been subject to conditions imposed by its interim orders panel.

Among them is a bar on Mr Berry carrying out hepatopancreaticobiliary surgery, including that performed on Mr Rogers.

A Royal College of Surgeons (RCS) report – commissioned by Cardiff and Vale University Health Board – stated that Mr Rogers’ acute liver failure was “possibly due to technical error at surgery with portal vein damage”.

It further stated that surgery showed evidence of “poor judgement and technical errors”, “reflecting poor operative skills” and that his death was “avoidable”.

In a statement, the health board confirmed a specialist liver surgeon working at the hospital was suspended last January “following concerns about the outcomes of some liver patients whilst in his care”. He was also referred to the GMC.

The health board commissioned the RCS to review its liver service, which confirmed its initial concerns. A second RCS review was commissioned into the care of 31 patients who underwent complex liver surgery performed by this surgeon.

The health board does not name the surgeon in its statement, which reveals that 10 of those 31 patients died following that surgery and “the outcome of this detailed review showed that eight of those 10 deaths were avoidable”.

Medical director Dr Graham Shortland said the health board’s normal checks on surgeons’ clinical outcomes had identified the original concerns, and no current liver patients are at risk.

“Every death is a tragedy for the family concerned, but we do not underestimate the impact of a death in these circumstances. We would like at the outset to put on record our unreserved apologies to Ms Davies, and every family who has been affected,” he said.

Mr Rogers had suffered bowel cancer, which spread to his liver, since 2010 but Ms Davies, who lives in Newport, said they understood that surgery would remove the tumours and prolong his life. “To learn that Martyn’s death could have been avoided is very difficult to comprehend and has left me feeling angry,” she said.

“I am also concerned that other patients may have been affected. I would also like to know what steps are being taken to ensure no-one else suffers the same unnecessary ordeal.”

Emma Rush, of Irwin Mitchell solicitors, representing Ms Davies, called the RCS report into Mr Rogers’ death “deeply concerning”.

Dr Shortland said the health board has been “in dialogue with the majority of those families concerned for some time and has put individual advocates in place to support them through this difficult period”.

“Our absolute focus is on the safety and quality of the care we give to our patients. Anomalies in this surgeon’s results were picked up by us from routine clinical data, which we scrutinise rigorously across the organisation,” he said.

“We have worked with the Royal College of Surgeons, and our own staff, to make sure we are clear about the numbers of people whose care and treatment may have been affected.

“We appreciate this is a worrying time for patients and their families and would like to reassure patients who are receiving or awaiting liver surgery at the moment that Cardiff and Vale UHB has full confidence in the current liver service at the University Hospital of Wales.”

A helpline – 0800 952 0244 ? has been set up for anyone concerned about the surgical care they received in relation to liver surgery between February 2011 and October 2012. It is open noon-8pm from today until Friday December 13.

 

 

THE FOLLOWING IS A STATEMENT FROM CARDIFF AND VALE UNIVERSITY HEALTH BOARD

Liver Surgery at the University Hospital of Wales: Statement

Cardiff and Vale University Health Board can confirm that a specialist liver surgeon working at the University Hospital of Wales was fully suspended from duty in January 2013 following concerns about the outcomes of some liver patients whilst in his care.

The experienced surgeon was employed by the UHB in February 2011. The UHB identified concerns about the care and treatment of a number his patients who had undergone liver surgery through its normal monitoring procedures in October 2012.

The surgeon was immediately placed on a period of restricted practice pending the outcome of an internal investigation, which confirmed the UHB’s initial concerns and resulted in the surgeon being fully suspended from all duties in January 2013. He was also referred to the General Medical Council. The surgeon concerned remains fully suspended.

The UHB subsequently commissioned an independent review of its liver service by the Royal College of Surgeons (RCS), the outcome of which reinforced the UHB’s view.

As a result, the UHB commissioned a second, detailed review by the RCS of the individual care of some 31 patients who underwent complex liver surgery by this surgeon, 10 of whom sadly died following that surgery. The outcome of this detailed review showed that eight of those 10 deaths were avoidable.

Medical Director, Dr Graham Shortland, said the UHB’s normal checks on surgeons’ clinical outcomes had identified the original concerns and that no current liver patients were at risk.

“Every death is a tragedy for the family concerned, but we do not underestimate the impact of a death in these circumstances. We would like at the outset to put on record our unreserved apologies to Ms Davies, and every family who has been affected.

“The UHB has been in dialogue with the majority of those families concerned for some time and has put individual advocates in place to support them through this difficult period. There are two families who have not responded to our repeated correspondence.

“As a health board, our absolute focus is on the safety and quality of the care we give to our patients. Anomalies in this surgeon’s results were picked up by us from routine clinical data, which we scrutinise rigorously across the organisation.

“We have worked with the Royal College of Surgeons, and our own staff, to make sure we are clear about the numbers of people whose care and treatment may have been affected by this issue.

“We appreciate this is a worrying time for patients and their families and would like to reassure patients who are receiving or awaiting liver surgery at the moment that the UHB has full confidence in the current liver service at the University Hospital of Wales.”

The UHB has set up a helpline for anyone who is concerned about the surgical care they received in relation to liver surgery between February 2011 and October 2012. The helpline number is 0800 952 0244 and will be open 12 noon to 8pm every day from Wednesday, December 11 to Friday, December 13.