An Independent Investigation Into the Care and Treatment of Mrs Elizabeth

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. Introduction 1.1 This report provides an independent account of the circumstances leading to the death of Mrs Elizabeth Rourke in the day surgery unit at Jersey General Hospital on 17 October 2006. It reports on the incident and the court proceedings in January 2009 when Dr Dolores Moyano faced a charge of gross negligence manslaughter. It describes the internal investigation carried out by hospital management in 2007 and the progress in implementing changes and improvements to hospital systems and processes. It makes conclusions about the wider causes of Mrs Rourke‟s death and proposes recommendations. 1.2 Mrs Rourke died at 6.25pm on 17 October 2006. She had been admitted for routine gynaecological surgery – a hysteroscopy for the removal of a possible polyp - and was expected to go home that day. She was the ninth patient on the morning list. She was a public patient under the care of Mr John Day, consultant obstetrician and gynaecologist, at the time of her death. 1.3 Mrs Rourke was a staff nurse at Jersey General Hospital and worked on Beauport ward. She had been employed in the hospital since 2002. 1.4 Mrs Rourke died from complications of massive blood loss. This followed the perforation of her uterus and injury to her left common iliac vein during surgery. 1.5 The health and social services department (HSSD) informed States of Jersey police of Mrs Rourke‟s unexpected death on the evening of 17 October. Initially police investigated on behalf of the Deputy Viscount (coroner). 1.6 Mr Day was advised to stay away from work and was subsequently formally excluded on 23 October by Mr Mike Pollard, at that time chief officer of HSSD. Mr Day remains excluded at the time of writing. 5 1.7 The death became a criminal investigation on 23 October and eventually Dr Moyano became its focus. She carried out the surgical procedure on Mrs Rourke on 17 October 2006 just after Mr Day had left the operating theatre. Dr Moyano was charged with gross negligence manslaughter on 27 September 2007 and tried at the Royal Court on 5 January 2009. She was found not guilty on 27 January 2009. 1.8 Mrs Rourke‟s unexpected and untimely death was devastating to her husband who works as a staff nurse on Portelet ward at Jersey General Hospital. It has also had a profound impact on Mrs Rourke‟s family and her professional colleagues at the hospital. The hospital has a reputation for providing safe care and the death of a patient in such circumstances was shocking. The death was the first on the day surgery unit. The tragedy was compounded by the fact that the hospital‟s own investigation of Mrs Rourke‟s death was restricted by the criminal process. 1.9 After the criminal trial Senator Jim Perchard, then Minister for Health and Social Services, announced an independent investigation into Mrs Rourke‟s death. Its purpose was to give a full account of the incident, review the hospital‟s internal investigation and make further recommendations about how patient safety could be improved. The minister asked Verita to conduct the investigation. He also wrote to Mrs Rourke‟s husband Bob to explain the purpose of the work. 1.10 Verita is a consultancy specialising in the management and conduct of investigations, reviews and inquiries in public sector organisations. Ed Marsden, managing director of Verita, Derek Mechen, director of client work and Lucy Scott- Moncrieff, associate, carried out the investigation. Mr Julian Woolfson, consultant obstetrician and gynaecologist adviser at the Royal College of Obstetricians and Gynaecologists (RCOG) and Verita associate has provided expert medical advice. All have wide experience of public services and conducting investigations. Dr Sally Adams was part of the investigation team at the outset. She stood down for personal reasons unconnected with the investigation. 6 1.11 We have had the benefit of the experience of Terry Hanafin CBE, until recently the chief operating officer for NHS London, who has acted as an adviser. Dr Jean- Pierre van Besouw, consultant cardiothoracic anaesthetist, St George‟s Hospital London, was nominated by the Royal College of Anaesthetists to provide expert advice. Mr Will Butcher, consultant vascular surgeon at the Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust and visiting consultant to Jersey General Hospital provided us with an opinion about matters concerning vascular surgery. Mr Butcher has left Bournemouth to take up a post abroad. 7 2. Terms of reference Commissioner 2.1 The Minister of Health and Social Services, States of Jersey, has commissioned this independent investigation as part of his general obligations to ensure the safety of health services and improve the quality of care for patients. The investigation has no disciplinary remit and will not consider the acts and omissions of individuals. Rather, it will provide a narrative explanation of the incident and consider organisational systems and processes. 2.2 The purpose of the independent investigation is given below: examine the care, treatment and management of Mrs Elizabeth Rourke from her related GP referral up until the start of the police investigation. review the main actions taken by the health and social services department in response to the death of Mrs Elizabeth Rourke including its own interim internal investigation. This will include establishing whether or not there are any significant omissions to the investigation and, if so, exploring these. review progress made against the recommendations of the interim internal investigation. identify any further actions that the Health and Social Services department should take to improve the safety and quality of health services. provide a written report with recommendations to the Minister. 2.3 The full terms of reference for the investigation appear at appendix A at the back of the report. 8 2.4 We provided a two-page private letter to the director of nursing and governance in May 2009 outlining progress with the investigation and identifying a small number of issues for the Minister and the management team to consider. We sent a copy of the letter to Tom Gales, our liaison officer from the Chief Minister‟s department, on 24 June. 2.5 Deputy Anne Pryke, who was elected Minister for Health and Social Services in late April 2009, reconfirmed the nature of the investigation in a meeting with us that month. 2.6 On 29 May 2009, Senator Stuart Syvret tabled a proposition in the States Assembly calling for the investigation to be stopped and a committee of inquiry set up in its place. States members debated this proposition in mid-June and agreed that the investigation team should make a presentation to them. Three members of the team appeared before States members on 24 June 2009 to give a presentation and answer questions. Members debated and voted on the matter on 30 June and 1 July and agreed by 35 votes to 15 that the investigation should continue. 2.7 After the presentation and the debate the minister wrote to us on 2 July and clarified and expanded on aspects of the terms of reference and her expectations about publication and the implementation of any recommendations. She invited us to produce an addendum to our report. The minister‟s letter is at appendix B. 2.8 In conducting the investigation we did not and do not challenge the verdict of the Royal Court. 9 3. Executive summary and recommendations The incident 3.1 Elizabeth Rourke died on the evening of 17 October 2006 as a result of a medical accident after a routine hysteroscopy in the day surgery unit at Jersey General Hospital. She worked at the hospital as a staff nurse on Beauport ward and had been referred by her GP to Mr John Day, consultant obstetrician and gynaecologist.

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