Report into three deaths at Stevenage Surgicentre
- Credit: Josh Massey
THE deaths of three patients following elective surgery at the privately-run Surgicentre have been criticised by the most experienced medical examiner in the country.
A catalogue of recommendations and concerns have been raised in the report by Dr Alan Fletcher, who was called in following the unexpected deaths.
In all of the cases a junior doctor was left to look after the patient after their routine surgery at the Stevenage facility, and Dr Fletcher noted a member of staff was working continuously for days and had no clear way to escalate problems to his or her superiors.
The report read: "That the same registered medical officer (RMO) made entries in the clinical records for over 48 hours at all times of the day and night makes me concerned this doctor was on an unacceptably arduous rota with little chance of rest because of his/her involvement with (patient 1) who was unwell.
"I'm not critical of this doctor's assessments or management in this case but would highlight how difficult it can be to manage patients safely when on a continuous 24-hour plus duty rota."
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In another case a vital piece of medical equipment was not available and a senior doctor only gave advice over the phone rather than reviewing the patient in person.
Dr Fletcher said: "There is a wide differential diagnosis when a patient deteriorates post-operatively and attempts to make a diagnosis were at a basic level.
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"A persistent deterioration should be escalated to senior doctors responsible for the patient and not left to the RMO to manage on their own."
Dr Fletcher is also critical of a request by a doctor who indicated to a coroner what a cause of death should be, stating some coroners would feel the patient would not have died had the elective surgery for a non-life-threatening condition not taken place.
The medical examiner also recommended: education of staff on post-operative complications, access to Lister Hospital's medical records for all surgical cases, abnormalities discovered before surgery should be investigated and access to senior surgical and medical staff is improved.
Following the release of the report, Stevenage MP Stephen McPartland has repeated his calls to have the Surgicentre’s licence revoked.
He said: "The report clearly shows there are still clear problems at the Surgicentre.
"I firmly believe they should have their licence to operate healthcare in the UK suspended and the facility should be returned to the East and North Herts NHS Trust."