HEALTH chiefs have been criticised after an inquiry into the deaths of three patients who had gall bladder surgery at Lanarkshire hospitals.
A sheriff said the patients, including Motherwell man Andrew Ritchie, might have survived had they been given better care after surgery.
Sheriff Robert Dickson also criticised senior medical staff at the hospitals for a lack of adequate patients’ notes.
His findings, after an inquiry in Cumbernauld last year, prompted an apology from NHS Lanarkshire.
Mr Ritchie (62), a former steelworker, of Burnside Tower, Motherwell, died nine days after an operation to remove his gall bladder at Wishaw General Hospital in June 2006.
The fatal accident inquiry investigated the deaths of Mr Ritchie, Agnes Nicol (50), of Carluke, and George Johnstone (54), of Airdrie.
Mrs Nicol died in March 2006 after gall bladder surgery at Wishaw and Mr Johnstone died in May that year after a similar operation at Monklands Hospital.
In his findings, Sheriff Robert Dickson said there were ‘clear faults’ in the care of each of the three patients after surgery.
He stated: “There was a lack of proper post-operative planning and the recording of those plans.
“There was clear evidence that when the patients were not responding as was expected this failed to result in the necessary investigation as to the cause.
“It is not possible definitively to say that if each patient had been returned to surgery earlier, and the necessary scans carried out timeously, lives would have been saved.
“However, had post-operative care been to the standard expected, and had there been a proper management plan which staff could have worked to, there remains a realistic possibility in each case that the death would not have occurred.
“In each case the consultant failed to consider the growing body of evidence that there was something fundamentally wrong with the patient and the most likely cause was something which had arisen during the operation.”
In Mr Ritchie’s case, consultant Mrs Lannigan assumed that bile leaking after the operation was coming from the gall bladder area when it was coming from the damaged duodenum. She admitted in evidence that she had been guilty of ‘tunnel vision’.
Sheriff Dickson said it was ‘regrettable’ that in 2005/06, at both Wishaw and Monklands, there was evidence that certain consultants failed to ensure ‘proper and appropriate’ medical notes were taken.
Sheriff Dickson stressed: “It is essential that every doctor and nurse responsible for the care of a patient has acccess to all the records and documents, and that full notes are available at all times.
“In relation to the care of Mrs Nicol, Mr Johnstone and Mr Ritchie, this was not so. I can only hope that NHS Lanarkshire will ensure in future that there is full documentation recorded by doctors and nurses at each stage of the treatment of patients and that the records department ensures that all the hospital records are kept and made available to all those who require access to them.”
Mr Ritchie, a bachelor, was well known as a cabaret singer.
His cousin Bill Ritchie was allowed to question witnesses at the inquiry and expressed concern that he had gone into hospital in generally good health but died a few days later.
Mr Ritchie declined to comment on the sheriff’s findings.
An NHS Lanarkshire spokesman said: “We fell below the high standards of care we aim to maintain in these cases and this has been extremely distressing for the patients’ families. We would like to take this opportunity to apologise to them.
“We have made significant improvements to the management of these types of cases and have also made significant changes to documentation and the way in which case notes are managed.
“However, we will study the determination in detail to identify if there are any further areas where we can improve.”