Thursday 22 February 2018

Botched op medics cleared by inquiry

Doctor breaks down over kidney blunder

The boy's parents
Jennifer Stewart and Oliver
Conroy
The boy's parents Jennifer Stewart and Oliver Conroy

A medical inquiry last night dramatically decided that two surgeons involved in removing the wrong kidney from a young boy had no case to answer.

The eight-year-old who was operated on at Our Lady's Hospital for Sick Children in Crumlin in March 2008 was left with one poorly functioning kidney and may need a transplant.

The junior doctor who removed the healthy kidney, Sri Paran, broke down in tears at yesterday's inquiry. He has since been offered a full-time consultant's post in Crumlin.

The senior surgeon, Martin Corbally, had asked Mr Paran to carry out the operation.

The inquiry was dramatically halted after four days of evidence. The Medical Council's fitness-to-practise committee decided neither medic had a case to answer.

It emerged that Mr Corbally came back to the theatre 45 minutes into the operation but by then the wrong kidney had been removed.

Mr Corbally said he had delegated the surgery to Mr Paran as he believed it was well within his competence.

The doctors will have to produce a joint report in the next year setting out the lessons to be learned from the blunder that might have been averted if the child's X-ray had been checked before the healthy kidney was removed.

The boy's parents Jennifer Stewart and Oliver Conroy said last night the doctors must be open, trusted and clear in their approach to work and colleagues.

"This was not prevalent in the treatment of our son and has ultimately led us to where we are," they said.

They said lessons had to be learned from the tragedy, warning that doctors had the lives "of our children in their hands". They added: "They must realise this when making decisions."

And they called on doctors to end the "hierarchical system" which they claimed to be a risk to the safety and quality of life of the patients they were entrusted with.

Chairman of the three-person Fitness to Practise committee Dr John Monaghan said there had been a series of catastrophic errors but the committee was not satisfied there had been any malicious intent or serious professional misconduct involved despite the tragic outcome.

Dr Monaghan said the three-person committee was guided by the parents' motivation to ensure the catastrophe could not happen to another child and their worries that their concerns they brought to the doctors went unheeded.

Recommendations

New procedures to reduce the risk of this happening again in Crumlin have been introduced, including ensuring X-rays are checked, will improve safety but several recommendations in an independent inquiry report have still to be followed.

The system of deferential behaviour between junior and senior consultants and cultural difference was a critical factor in this case and the two doctors needed to address this.

Earlier, Mr Paran wept yesterday and admitted that he "had a chance and he did not take it" to check the child's X-ray after he started surgery on the boy and saw the kidney he was about to remove may be healthy.

He said he was not due to carry out the operation, which took place on Good Friday, and was given just five minutes to prepare. Prof Corbally, who was due to do the surgery as the child's consultant, had listed the wrong kidney for removal.

"The Professor said are you happy to go ahead with this. I was taken aback . . . if a consultant says you do something you do it and you don't dictate what happens where."

Mr Paran, a native of Sri Lanka who studied medicine in Galway, became emotional as he said: "When you are with a mentor over a period of years you develop a trust. When a consultant says make an incision I trust he has done whatever needs to be done.

"As a mentor not only do you train the person but you also have a job to protect that person. I trusted what I was told."

When he made an early incision he saw that the kidney looked slightly pink and smooth and "it hit me it's not too bad".

He looked again at the consent form but did not check the X-rays.

"I was led into it.I had a chance and I did not take it."

Prof Corbally, in earlier evidence, admitted that he wrongly listed the kidney to be removed but he said Mr Paran should have double-checked the X-ray before beginning surgery. He said Mr Paran had about 30 minutes to prepare.

The boy's parents told how they had spoken to staff on several occasions to double-check which kidney was to be removed.

Mr Paran drove to the hospital on Easter Sunday to talk to the parents "for his own sanity" although he had been advised earlier not to because other doctors said they had enough on their plate.

"I told them I was the one who physically did the damage. They were surprised to hear that," he said.

A spokesperson for Crumlin Hospital was not available yesterday to answer questions on the tragedy and what steps have been taken to minimise the risk to other patients.

Irish Independent

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