THE J.E.P ARTICLES
Read the unabridged, full text of the two articles.
A lot of readers have asked if it was possible to post the full text from the two articles from today’s Jersey Evening Post.
Unusually for the paper – it has actually done an excellent job – and exposed a truly shocking catalogue of management failures – and subsequent cover-ups – concerning the death of Elizabeth Rourke.
I have managed to scan, convert to PDF and then eCopy to Word the articles – which I reproduce in full below.
I’d be interested to know from readers in other jurisdictions just what would be the fate of the senior management personal involved in this farrago – if it had occurred in your nation.
Here are the articles; they make disturbing reading.
You just couldn’t make it up.
From the Jersey Evening Post, 31st January, 2009
WARNINGS THAT WERE MISSED
Hospital death: Internal reports raised concerns about performance of doctor put on trial.
TWO internal Hospital reports raising concerns about the performance of Dr Dolores Moyano Ontiveros were made prior to the routine operation which resulted in the death of a staff nurse.
The JEP has learned that the two ‘incident reports’ about Dr Moyano were made in the days leading up to the gynaecological procedure she carried out on Elizabeth Rourke.
But those in charge of the doctor either failed to act or the incident reports did not reach them in time to stop Dr Moyano from operating while they were investigated. One of them involved a caesarean delivery just days before Mrs Rourke’s death.
This week Dr Moyano was cleared of the manslaughter of Mrs Rourke, who died following complications encountered during her operation in October 2006.
Hospital management denied the existence of any written concerns at the press conference on Wednesday which followed the acquittal and yesterday Richard Jouault, deputy chief executive of Health, said that ‘he could not confirm the existence of the reports’.
However, after he was informed by the JEP that the documents were presented in court during the trial, but in the absence of the jury, he retracted his earlier statement and agreed that the incident reports did exist, saying that the police had checked all the incident reports concerning Dr Moyano and gynaecologist John Day during their investigations.
‘I can confirm police have all the incident reports relating to Dr Moyano.
‘I cannot confirm how many there are or what they are about, but they were obviously filled out earlier than Elizabeth Rourke’s operation.’
Mr Jouault initially refused to be drawn on whether the reporting system for incident reports at the Hospital was flawed.
But then he said: ‘If a report has been received and had been investigated and no action was taken, then that is a problem.
‘We are not shirking our responsibilities, but this has to be done properly with the General Medical Council and an external hospital investigation.’
The existence of the reports was not actually revealed in open court during evidence, but by Crown Advocate Howard Sharp in the absence of the jury when he was objecting to a number of character references of Dr Moyano being read by the defence.
Advocate Sharp told the court: ‘On the Monday before Mrs Rourke’s operation, an incident form was filled out and complained that Dr Moyano didn’t know what she was doing.
‘On the Friday before, an incident report completed about someone undergoing a Caesarean delivery said that “not sure that Dr Moyano always performed her duties with utmost care and diligence”‘.
Mrs Rourke died from ‘catastrophic internal bleeding’ after complications including a perforated womb and damaged main vein following an operation carried out by Dr Moyano, and despite hours of emergency surgery.
Mr Jouault said that the Hospital used a system called Datix that logged all the incident reports, which could be entered electronically or on a paper form. They could be filled in by staff ranging from cleaners to consultants and once put on the system, responsibility was passed to a risk manager, according to Mr Jouault.
He said it was then up to the risk manager to flag up any ‘odd’ incidents.
‘Depending on what the incident was and the risks involved with that, such as an unsafe incident, it could make it to the top of an organisation as to how it is managed,’ he said.
‘The risk manager makes that judgment.’
He said that the Health and Safety manager responsible for the reporting system at the time had since retired.
Asked again whether there were failings in the Hospital relating to Dr Moyano and the fact that her competence had come into question, yet she was left unattended during surgery just days later, he said: ‘We have not been able to see the relevance of these forms – the Crown Advocate has these reports.’
Jersey Evening Post, 31st January, 2009.
REVIEW TEAM MEMBER WAS IN TRAGEDY THEATRE
One of the consultants who was involved in the battle to save Elizabeth Rourke was asked to be involved in an internal review into how she died.
It was denied this week by Health director Mike Pollard and a senior colleague, James Le Feuvre, that Dr Richard Lane was involved in any sort of internal inquiry.
But during a subsequent telephone conversation with the JEP Dr Lane confirmed that he was involved in the early inquiries and did not see any conflict of interest in investigating the matter despite being involved in the attempt to save Mrs Rourke’s life. However, he denied being the ‘case manager’ on the inquiry and denied that any such title existed in Jersey when a ‘Serious Untoward Incident’ was being investigated.
He also went on to say that the internal investigation as a whole was almost immediately put on hold after the tragedy in October 2006 because criminal proceedings had begun.
However, an e-mail seen by the JEP shows that Dr Lane was still being referred to in March the following year as the ‘case manager’ for the inquiry. The e-mail, which was sent from the human resources department at the General Hospital, to both Dr Lane and another doctor, said: “… I’ve had to allocate roles as per the procedure. Dr Lane you’re the Case Manager (as MD this is appropriate). The guidelines state that you must consider all the issues around pay, exclusion from the premises, keeping in contact, cpd [continuous professional development] etc, which you’ve been doing.’
The e-mail stated that it was time to send a report to the NHS and asked Dr Lane, as case manager, to do this.
But this week Dr Lane denied being a case manager. He said: ‘I did not lead any internal investigation and we do not have case managers in Jersey on a Serious Untoward Incident’.
‘We did conduct an interim report, looking into our own internal procedures – but it didn’t continue, as we were asked to stop.’
He went on to explain that following a Serious Untoward Incident, a panel of officials meet almost immediately to assess what to do. He said that he was part of that initial meeting but did not lead any investigations.
However, this was contrary to what Mr Pollard had told the media this week, which was that Dr Lane was never ‘involved in any internal investigation’, and further contrary to the leaked email, which clearly calls Dr Lane the case manager almost six months after the death.
Asked whether he thought his role on the panel and in any investigation involved a conflict of interest, Dr Lane said: ‘how can it be a conflict?’
After being reminded that he was one of the consultants involved in trying to save Mrs. Rourke for a number of hours, he said: ‘I was the consultant anaesthetist on call that day. If I was called to an incident then I had to go. There was no conflict there, and especially as we didn’t proceed with any investigation.’
Dr Lane’s role in the theatre that day was considered significant enough for him to be interviewed or spoken to by a leading UK consultant who was sent to Jersey to conduct a post-mortem on Mrs Rourke just four days after she died.
These events have raised questions about how and why someone with such direct involvement in an incident was allowed to be involved in an investigation and then be allowed to forward findings to the National Clinical Assessment Service at the NHS, which looks after patient safety in the UK.
Yesterday Richard Jouault, the deputy chief executive of Health, said that after a Serious Untoward Incident at the Hospital, a panel was set up which included himself and Dr Lane. He said that in this instance, anaesthetist Graham Prince was assigned to lead that.
When asked if Dr Lane was involved in the investigation, Mr Jouault said: “Absolutely he wasn’t involved.”
Asked whether there would have been a conflict of interest if Dr Lane had been involved, he said: “I would have thought so if he had been, yes.”
Jersey Evening Post, 31st January, 2009