.A widow died on an operating table after a surgeon tried to remove the wrong organ, an inquest heard today.
Widow dies on operating table when surgeon tries to remove liver instead of her kidney
- Amy Francis underwent surgery for kidney cancer
- Trainee loses confidence during operation
- Liver ruptures causing death
- Hospital admits to error
Amy Francis, 77, underwent keyhole surgery to remove a cancerous right kidney last July.
But during the operation at the Royal Gwent Hospital, Newport, her liver ruptured as it was mistakenly pulled out and, despite desperate efforts to save her, she died of internal bleeding.
Consultant urologist Dr Adam Carter, admitted to the error and highlighted that as a result of the death, a modified operating procedure had been communicated ‘worldwide’.
Her son Alan, 52, praised Dr Carter for his honesty and the hospital for ‘owning up’ early.
Following the hearing he said: ‘We appreciated Mr Carter’s honesty and him coming along here today and hope that we can put it all behind us now.
‘I think that it was the honesty that saved the hospital. If we thought that they had not answered our questions it would have been different.
‘This was an honest mistake.’
Retired accountant, Mrs Francis, was diagnosed with kidney cancer and was due to be treated after she had recovered from the routine surgery.
But during the operation Dr Carter allowed a trainee, who had never performed the procedure before, to locate and remove the organ.
As the trainee wasn’t confident enough to remove the organ Dr Carter was forced to take over, and during the changeover confusion occurred.
When he attempted to remove the kidney he was immediately told by the anesthetist that the patient’s blood pressure was dropping and he realised his mistake.
Consultant urologist Dr Adam Carter, admitted to the fatal error during an operation performed at the Royal Gwent Hospital
Two senior surgeons were called to the scene and every effort was made to save Mrs Francis, but they were unsuccessful.
David Bowen, the coroner for Gwent, said: ‘Whilst undergoing keyhole surgery for the necessary removal of the cancerous kidney, Mrs Francis’s liver was ruptured when it was mistakenly and unintentionally identified as the kidney and was catastrophically torn and damaged, resulting in death.’
Dr Carter said he had carried out the procedure 20 times since the death without a problem.
Son Alan said before the inquest finished: ‘We accept the decision and we also accept that Mr Carter and his team acted in good faith to prolong my mother’s life.
‘We also appreciated his honesty and wish him well for the future and hope he goes on to do other successful operations.’
Over the last 40 years, the number of cases of kidney cancer has doubled in men and risen by 130 per cent in women, a trend which is believed to be linked to rising obesity figures.
There were 3638 new cases diagnosed in men and 2118 new cases diagnosed in woman in England during 2007.
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I received this same operation 05-Sep-2001, in the same theater, but then laparascopic surgery for a nephrectomy due to cancer was NOT often practiced and my operation was a full open operation sadly this increases the risks of infection and prolongues recovery but despite serious infection and a fully herniated wound the operation saved my life.
YES accidents happen in surgery as it is not an exact science – Obviously there was no intention to cause an infection nor intent to create a massive inoperable hernia – It is called an accident and I totally endorse the attitude of Mrs. Francis’s family, I also endorse the decision to protect the tranee surgeon from identification and clearly the responsibility, if not the action, was Adam Carter’s.
I have known Adam Carter since before he took over leading the team when Windsor Bowsher sadly died 11-May-2011. His actions in this issue have been entirely honourable as I would expect and I would be happy to have him operate on me, if I ever need further complex surgery.
Some weeks after my operation a friend of mine, who is a senior nurse at the same hospital, lost her father on that same operating table whilst having a nephrectomy due to cancer.
In his case the death was unrelated to his cancer or his kidney as he died of a massive heart attack at the very start of the operation and despite being in exactly the right pl;ace to help him survive the team were unable to revive him.
Yes accidents and tragedies happen and the risks are higher in hospitals but with a clear case of an accident that the hospital and medical team immediately keep the family or victim informed – unless there is clear negligence or similar – there is no moral ‘right’ to capitalise on the accident.
I am sure that Mrs. Francis would have been proud of her family’s response to her unfortunate ACCIDENT, just as I applaud Adam Carter’s courage in being totally transparent.