Death of an elderly woman in surgery prompts hospital changes

Monday 24 April 2017

An inquest has heard how the death of a 84-year-old woman during surgery at the hospital has led to new procedures to help junior staff challenge their seniors.

Collette Louise Falle died following an operation on 1 November 2015.

The mother of six, had been admitted to the hospital two days before her death with severe pain in her upper abdomen. She was diagnosed with acute inflammation of the gall bladder, which needed to be removed. In doing so, her surgeon damaged one of her main veins. Efforts to identify the source of the haemorrhage failed, and Mrs Falle subsequently died. 

At the inquest of Friday, various experts stated that all efforts had been made to save Mrs Falle's life, but they also noted that there had been a failure to realise the extent of the haemorrhage and to rescue the situation. It was also noted that, given the location of the haemorrhage, at the back of the abdomen, it would have been difficult to assess the extent of the bleeding.

The inquest, chaired by Deputy Viscount Mark Harris, heard that medical staff who were in the operating theatre at the time, had been concerned with the possibility of an extensive bleed, but didn't communicate adequately with the lead surgeon. 

Speaking at the inquest, Martyn Siodlak, Medical Director at the hospital, explained that steps had now been taken to make sure that junior staff speak up to senior staff. He said: "We are continually encouraging the operating staff to challenge surgeons. That is why we have team briefs where everyone gets introduced and states their first name. It is difficult because many junior staff still say they feel inhibited by senior staff."

On the issue that no other surgeon was brought in to try and resolve the situation, Gerald Williams, a consultant vascular surgeon, who delivered a Case Review Investigation Report, said: "We have agreed as a hospital that trying to get as much help as possible and getting an experienced consultant in the theatre, whether or not they have expertise on the particular matter, should be the way forward. It is unfortunate that other surgeons were not involved as they may have helped to resolve the situation."