Lalitab en Jayantibhai Patel · Prevention of Future Deaths report

On the 21st December 2012 I commenced an investigation into the death of Lalitaben Jayantibhai Patel. The investigation concluded at the end of the inquest on the 11th March 2014. The conclusion of the inquest was a narrative conclusion which in summary recorded that inappropriate dissection during an elective cholecystectomy on the 4th May 2012 resulted in a series of complications which ultimately led to her death on the 20th December 2012 at the Leicester General Hospital.

Mrs Patel underwent elective laparoscopic cholecystectomy at the Leicester Royal Infirmary on the 4th May 2012. During the initial stages of the procedure the surgeon undertook inappropriate dissection leading to a damaged vessel near to the common bile duct which subsequently ruptured resulting in a massive secondary haemorrhage. This in turn led to Mrs Patel suffering problems after her surgery, hypoxic brain injury and her death on the 20th December 2012 at the Leicester General Hospital.

(1) The surgeon who had responsibility for the elective cholecystectomy was a Locum Consultant Surgeon and was in the second week of his 4 weeks contract. Evidence was heard that he had been appointed via an agency following which he undertook two practical assessments at the University Hospitals Leicester. In summary, there were two main issues highlighted by both assessing Consultants on two separate days resulting in a decision to restrict the Locum Consultant Surgeon to conducting routine laparoscopic cholecystectomies. However, as this was a Consultant grade Locum, no other supervision was provided in respect of the cases under his clinical management.

Evidence revealed that the systems in place at the material time for signing off a locum Consultant as competent to undertake independent practice were not as robust as they should have been.

The inquest heard that University Hospitals Leicester have now changed their recruitment process for Locums and that Locums must be recruited by the ‘Locum Bookers’ team in accordance with Trust policy. In addition the processes for signing off a locum consultant as competent are more robust.

However, it is understood that in other areas the practice for appointing locums is not so robust and mirrors the practice undertaken at the material time. Accordingly, there is a real risk that what happened in this case could happen elsewhere.