The NWEMail 5 August 2019
THE families of two patients who died after being failed by FGH consultant urologists have spoken of their fury at finding out they were allowed to repeat their mistakes.
Following a lengthy investigation by The Mail the families of Irene Erhart from Walney and Peter Read from near Morecambe have also now been made aware that the under-fire department continues to employ two consultants who made ‘catastrophic’ errors.
A third consultant chose to resign from the University Hospitals of Morecambe Bay NHS Foundation Trust last September.
he hospital trust has now apologised to both families.
FAMILY’S SHOCK DISCOVERY
The Mail’s investigation led to Mrs Erhart’s husband Garth finding out this week that four years after his wife Irene died the same consultant made similar mistakes which a coroner said contributed to the death of another patient.
Mrs Erhart, a former comptometrist at Barrow steelworks, was 79 when she died on February 7, 2011.
She had been admitted to FGH on December 3 in 2010 with a systemic infection which had originated in her urinary tract. She was already awaiting a date for surgery to remove a kidney stone and had a history of urinary infections.
During the following four weeks her husband said two consultants; Ashutosh Jain and Kavinder Madhra, treated her solely with antibiotics and took no further action despite her deterioration.
“They never came and spoke to me, or my son, to explain what they were doing; because they did nothing for my beautiful wife, it was obvious she was dying,” Mr Erhart, 89, said.
Mrs Erhart continued to worsen and, by the end of January, ward staff were so worried about the consultants’ failure to act that a senior sister called consultant urologist Peter Duffy who was then based at the Royal Lancaster Infirmary.
Mr Duffy, who was constructively dismissed from UHMBT in 2016 after claiming his whistleblowing about his colleagues had been ignored, said the sister told him: “The two clinicians in charge of her care were doing nothing and all the ward staff were frightened she was going to die.”
The Mail has also spoken to the sister who took the unorthodox step of calling Mr Duffy.
“On a number of occasions I called Peter and asked him to come over because I thought Mr Jain and Mr Madhra were failing patients,” she said.
Mr Duffy, who now works on the Isle of Man, travelled to FGH on a day off and arrived to find ‘a very, very sick and septic lady who was clearly dying’.
He said: “The ideal time to operate had already come and long gone.”
Mr Duffy then advised Mrs Erhart’s family that operating was very risky given her condition but without surgery she would die.
Mr Duffy rushed Mrs Erhart to theatre but ‘it was much too late and she died a few days later’.
CORONER RULES MISTAKES CONTRIBUTED TO DEATH
Following an inquest in October 2011 deputy coroner Philip Sharp recorded a conclusion which stated: “The cause of death was contributed to by the failure to provide a stent to drain Mrs Erhart’s infection earlier in her treatment.”
The deputy coroner concluded that ‘Mrs Erhart should have been considered suitable for a stent much earlier in her admission which would have given her much better prospects’.
“By the time (Mr Duffy) looked at the situation the operation was necessary and it perhaps had been necessary for some time,” he added.
The deputy coroner praised Mr Duffy for his attempts, ‘to the best of his ability’, to save Mrs Erhart’s life by carrying out an operation which ‘had not been considered by those previously treating her’.
Speaking from his home in Strathmore Avenue on Walney, Mr Erhart, a retired shipyard fitter who also served in the Merchant Navy, said the hospital trust should have sacked both consultants at the time.
“The pain, the anger, it’s never faded. You just learn to live with it,” he said.
“Both of those doctors should have been struck off. It’s scandalous that one is still there and the other was allowed to continue working there for seven years ‘til he left.”
MEDICS MADE SAME MISTAKE FOUR YEARS LATER
In 2015, four years after Mrs Erhart died, Peter Read died after developing urosepsis, caused by ‘missed opportunities to change his ureteric stent’, a coroner later ruled.
Mr Read was treated by Ashutosh Jain, the same consultant who, in 2011, was involved in the care of Mrs Erhart.
A coroner said the failings of Mr Jain and fellow urological consultant Saleem Naseem in not putting in a kidney stent contributed to Mr Read’s death. Both still work at the University Hospitals of Morecambe Bay NHS Foundation Trust.
CATASTROPHIC OUTCOME OF FAILINGS
The Mail has now obtained a copy of a Root Cause Analysis investigation carried out by the hospital trust after Mr Read’s death on the request of the coroner. The trust was asked to produce the report by the coroner to explain why ‘despite microbiological advice the overdue and almost certainly blocked stent was not changed’ sooner.
Mr Read was admitted to Royal Lancaster Infirmary in December 2015 after a series of admissions for vomiting and stomach pain.
His condition deteriorated over a number of weeks but neither Mr Jain or Mr Naseem changed the stent when he became acutely unwell with sepsis.
The trust admitted, in the RCA, that there had been ‘two missed opportunities to change the stent’.
Peter Duffy was made aware of the situation on December 30 and replaced the stent during his lunch break as an emergency.
As with the case of Irene Erhart however, it was too late, and Mr Read died on January 2 after a CT scan revealed a brain stem death.
The RCA report highlighted missing medical records, ‘virtually illegible’ notes, a failure to review antibiotic treatment, and an 11-day period when Mr Read did not receive any nutrition.
Failing to request routine blood tests, consultants’ signatures on Mr Read’s notes which could not be deciphered, and not escalating his care sooner were also identified as errors.
FAMILY SAYS ‘LESSONS WERE NOT LEARNED’
His daughters Karen Beamer and Nicola Read were horrified to discover this week, as a result of information obtained by The Mail, that Mr Jain had been involved in the care of Mrs Erhart and that a coroner ruled a lack of action contributed to her death.
“In 2011 a coroner ruled failings in the care of Irene contributed to her death and clearly, despite what the trust claim, lessons were not learned,” Mrs Beamer said.
Mrs Beamer has praised Mr Duffy for trying to save her dad.
“Peter did everything he could,” she said.
“The trust has lost quite possibly the best urological consultant they have ever had. And Mr Jain and Mr Naseem are still employed and earning huge salaries paid for by the public.”
THREE CONSULTANTS ALLOWED TO CONTINUE WORKING
Kavinder Madhra started work for the trust in 2001 but the following year was sent off for 18 months to retrain at UHMBT’s expense after he was issued a warning by the General Medical Council because of clinical errors.
He returned but concerns continued to emerge with one of the most serious in 2014 almost resulting in a patient having the wrong kidney removed instead of a cancerous one.
Two months later five complaints were made about Mr Madhra by two patients and three doctors on the same day.
He was suspended and the trust asked the Royal College of Surgeons conduct an investigation. They concluded there were ‘very significant concerns’ and Mr Madhra was demoted but allowed to continue working at the trust while supervised.
Mr Madhra, 63, resigned from UHMBT in September 2018 nine days after the General Medical Council imposed conditions on his practice following numerous concerns about his abilities.
One of the most serious of his errors during his UHMBT career almost resulted in a patient having the wrong kidney being removed.
A hearing at the Medical Practitioners Tribunal Service to decide if Mr Madhra is fit to practice has started and has been adjourned until January 2020 because of availability of panel members.
Mr Jain and Mr Naseem, whose failings over a number of years have included other patients being left suffering from kidney failure and one 16-year-old boy who lost a testicle, continue to work at the trust.
HOSPITAL TRUST SAYS SORRY
The hospital trust has issued a lengthy statement apologising to the families of Mrs Erhart and Mr Read.
Medical director Dr David Walker (pictured) said: “We feel deeply sorry for Mr Erhart, and for the family of Mr Read and want to apologise to, and reassure them and your readers, that we take every case where a patient dies extremely seriously and that safety for our patients is our primary aim as a healthcare organisation.
“Because of that over-riding concern with safety, and in the light of a number of concerns raised about the Urology Department, including these cases from 2011 and 2015, we invited a review of the department by the Royal College of Surgeons in 2016.
“We have additionally carried out a huge amount of work to ensure the culture in the department continues to improve to ensure the best care for our patients and that our staff are well supported at work.
“In the autumn we will be undertaking a peer review of the department by expert clinicians from another trust to ensure that the actions arising out of the Royal College Review have been fully embedded and ensure there are no further actions required.
“In terms of the cases referred to, we have fully co-operated with the coroner in both cases at the time and ensured the coroner was satisfied we had taken all actions that we should.
“We appreciate that this is very traumatic for Mrs Erhart’s husband and Mr Read’s family and in Mr Read’s case have met with the family.
“We would also be pleased to meet with Mr Erhart and discuss any aspect of the case with him.
“We want to assure them that our investigations have been thorough, we have learned lessons and of course if Mr Duffy has any further information we’d be grateful to hear from him.”
FAMILY SAYS ‘TOO LITTLE TOO LATE’
In response to the trust’s statement Mrs Erhart’s son Lyndon said the apology was ‘too little and far too late’.
“Why has it taken the paper’s investigation, eight years on, for them to say sorry?” he asked.
“They knew when mum died that mistakes had been made but they never came to speak to us.”