An independent investigation into the care, treatment and management of Mrs Elizabeth Rourke A report for the Minister for Health and Social Services, States of Jersey January 2010 Authors: Ed Marsden Derek Mechen Lucy Scott-Moncrieff Julian Woolfson © Verita 2010 Verita is an independent consultancy which specialises in conducting and managing investigations, reviews and inquiries for public sector and statutory organisations. Verita 53 Frith St London W1D 4SN Telephone 020 7494 5670 Fax 020 7734 9325 Email
[email protected] Website www.verita.net 2 Contents 1. Introduction 5 2. Terms of reference 8 3. Executive summary and recommendations 10 4. Approach, structure and those involved 24 Part one 5. Obstetrics and gynaecology 36 6. The police investigation and Dr Moyano‟s trial 44 7. Elizabeth Rourke‟s care, treatment and management 47 8. The recruitment and employment of Dr Moyano 93 9. The allegations against Mr Day and Dr Moyano 130 10. The interim serious untoward incident investigation 162 Part two 11. Jersey General Hospital 189 12. The surgical directorate 210 13. The day surgery unit 215 Part three 14. The factors that contributed to Mrs Rourke‟s death 221 Appendices Appendix A Terms of reference 228 Appendix B Letter from Minister to the investigation team 230 Appendix C Documents reviewed 232 Appendix D Royal College of Anaethetists report 234 Appendix E Chronology 244 Appendix F Dr Moyano‟s CV and references 262 Appendix G Surgical procedures involving Dr Moyano 290 Appendix H Operation list of 17 October 292 Appendix I Letter from Graham Prince to Rose Naylor 293 Appendix J SUI recommendations – HSSD progress report 298 Appendix K UK approved service providers 305 3 Appendix L WHO pre-operative/surgical safety checklist 307 Appendix M Notes on the creation of an operating list 308 Appendix N Notes on the pre-admission assessment 310 Appendix O Notes on the day surgery procedure 312 Appendix P Notes on medical training and qualifications 313 Appendix Q Team biographies 315 4 1.