Lalitaben Patel
PFD Report
All Responded
Ref: 2014-0175
All 1 response received
· Deadline: 8 Jun 2014
Coroner's Concerns (AI summary)
A locum consultant surgeon, despite being restricted to routine procedures, operated without additional supervision, raising concerns about oversight for consultants with identified limitations.
View full coroner's concerns
(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management.
Responses
Action Planned
DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations. (AI summary)
DHSC highlights recommendations from a 2013 working group to strengthen quality assurance of locum doctors, including strengthened GMC appraisal guidance, pre-employment standards, audit guides, and guidance for Trusts. DHSC continues to welcome progress against these recommendations. (AI summary)
View full response
From the Rt Hon Jeremy Hunt MP
• Secretary of State for Health Department of Health Richmond House 79 Whitehall London SIVIA 2NS
Mrs Catherine Mason HM Coroner for Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LEI 9BG J(1.J 1,,.,-, • f,/'-.t.J~A > Thank you for your letter about the death ofLalitaben Patel. Your report advised that, Mrs Patel died from post-operative problems following an elective laparoscopic cholecystectomy surge1y by a locum doctor at the Leicester Royal Infirmary. I am pleased to note that your concerns about the recruiting and management practices at the Trust have now been addressed. However, your report raised wider concerns about the practice for appointing locum doctors elsewhere. The issue of quality assurance of locum doctors working in secondary care is clearly important. In November 2013, a high level Secondaiy Care Locum Doctor Working Group ( established by the Health Minister ) made a series ofrecommendations to strengthen existing atTangements and these were welcomed by the Government. They include: " Strengthening General Medical Council appraisal guidance for doctors particularly the need to report on any locum work undertaken. " Strengthening guidance to responsible officers (ROs) to ensure they check with doctors that locum work has been recorded. " NHS Employers Pre-Employment Standards being strengthened to include a seventh standard - covering the need for an employer to be provided with information about an individual locum's RO, dates of revalidation, and appraisal; and that the employer should check an individual is not only fit for practice but purpose.
• NHS Employers publishing a standard audit guide for pre-employment locum checks, providing greater confidence in audits and checks.
• Strengthening guidance for Trusts, emphasising the desirability of using framework locum agencies, with a section included on best practice when using non-framework agencies.
• NHS Employers issuing guidance to Trusts suggesting the development of a set of core measurements on locum usage, which will give boards visibility oflocum usage and quality assurance processes.
• Providing guidance to T1usts on best practice with regards to quality assurance controls, which sets out minimum requirements. I continue to welcome progress against these recommendations. I hope that this infonnation has been helpful and I thank you for bringing the circumstances ofMrs Patel's death to my attention. JEREMYHUNT
• Secretary of State for Health Department of Health Richmond House 79 Whitehall London SIVIA 2NS
Mrs Catherine Mason HM Coroner for Leicester City and South Leicestershire The Town Hall Town Hall Square Leicester LEI 9BG J(1.J 1,,.,-, • f,/'-.t.J~A > Thank you for your letter about the death ofLalitaben Patel. Your report advised that, Mrs Patel died from post-operative problems following an elective laparoscopic cholecystectomy surge1y by a locum doctor at the Leicester Royal Infirmary. I am pleased to note that your concerns about the recruiting and management practices at the Trust have now been addressed. However, your report raised wider concerns about the practice for appointing locum doctors elsewhere. The issue of quality assurance of locum doctors working in secondary care is clearly important. In November 2013, a high level Secondaiy Care Locum Doctor Working Group ( established by the Health Minister ) made a series ofrecommendations to strengthen existing atTangements and these were welcomed by the Government. They include: " Strengthening General Medical Council appraisal guidance for doctors particularly the need to report on any locum work undertaken. " Strengthening guidance to responsible officers (ROs) to ensure they check with doctors that locum work has been recorded. " NHS Employers Pre-Employment Standards being strengthened to include a seventh standard - covering the need for an employer to be provided with information about an individual locum's RO, dates of revalidation, and appraisal; and that the employer should check an individual is not only fit for practice but purpose.
• NHS Employers publishing a standard audit guide for pre-employment locum checks, providing greater confidence in audits and checks.
• Strengthening guidance for Trusts, emphasising the desirability of using framework locum agencies, with a section included on best practice when using non-framework agencies.
• NHS Employers issuing guidance to Trusts suggesting the development of a set of core measurements on locum usage, which will give boards visibility oflocum usage and quality assurance processes.
• Providing guidance to T1usts on best practice with regards to quality assurance controls, which sets out minimum requirements. I continue to welcome progress against these recommendations. I hope that this infonnation has been helpful and I thank you for bringing the circumstances ofMrs Patel's death to my attention. JEREMYHUNT
Sent To
- Department of Health and Social Care
Response Status
Linked responses
1 of 1
56-Day Deadline
8 Jun 2014
All responses received
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On the 21st December 2012 I commenced an investigation into the death of Lalitaben Jayantibhai Patel. The investigation concluded at the end of the inquest on the 11th March 2014. The conclusion of the inquest was a narrative conclusion which in summary recorded that inappropriate dissection during an elective cholecystectomy on the 4th May 2012 resulted in a series of complications which ultimately led to her death on the 20th December 2012 at the Leicester General Hospital.
Circumstances of the Death
Mrs Patel underwent elective laparoscopic cholecystectomy at the Leicester Royal Infirmary on the 4th May 2012. During the initial stages of the procedure the surgeon undertook inappropriate dissection leading to a damaged vessel near to the common bile duct which subsequently ruptured resulting in a massive secondary haemorrhage. This in turn led to Mrs Patel suffering problems after her surgery, hypoxic brain injury and her death on the 20th December 2012 at the Leicester General Hospital.
Copies Sent To
Chief Executive, University Hospitals Leicester
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.