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Home   Maidstone   News   Article

Maidstone and Tunbridge Wells NHS Trust publishes full report into keyhole cancer surgery which led to five deaths

15 May 2014
by Kent Messenger reporter

Maidstone and Tunbridge Wells NHS Trust has made a dramatic U-turn and finally published the full report into five avoidable deaths.

The five patients all died as a result of keyhole surgery for upper gastrointestinal (GI) cancer at the Trust's Hermitage Lane site in Maidstone in 2012 and 2013.

Specialist cancer surgery has been suspended at Maidstone Hospital

Specialist cancer surgery has been suspended at Maidstone Hospital

It revealed today that the full details have now been shared with families of patients who died from avoidable complications following the laparoscopic procedure.

It had earlier refused to divulge anything but the recommendations following an independent review by the Royal College of Surgeons in October 2013. The Trust received the Royal College's report at the end of December. The RCS said it had no objection to its report being published.

Surgery was suspended in July last year while the RCS conducted its investigations into the high death rates. The hospital provided the service to local patients as well as those referred from East Kent Hospitals, Medway and Darent Valley.

The Trust today said it was releasing the report following concerns raised by patients and their families that it may contain 'pertinent information relating to the management and care of their loved ones'.

Reviewers concluded that patient safety concerns existed for the following reasons:

  • High complication rate associated with the laparoscopic techniques used
  • Poor management of complications
  • Some deaths occurred as a result of unusual complications, probably associated with the surgical techniques used
  • Poor insight by the minimally invasive consultants into deficiencies in the service
  • Dysfunctional working relationships between surgeons
  • Inadequate consent process
  • Ineffective multi-disciplinary management working due to poor attendance by the minimally invasive surgeons
  • A number of questionable decisions to proceed with radical surgery in the presence of advanced and incurable cancer

A spokesman said at the time that staff had been “held to account” but the standard of practice did not support further sanctions.

Dr Paul Sigston, medical director for MTW, said: "I would again like to apologise to the families involved.

"We are now able to share this report with them that forms part of an in-depth investigation carried out by the Trust.

"It is our absolute intention to provide families with the answers they seek and we will continue to meet with them to discuss their loved one's care."

As well as reviewing the procedure, the Trust also examined general surgical outcomes for the consultants concerned and found no cause for concern.

It said it also reviewed its surgical services as a whole and "remains assured these are of a high standard". 

Action by the RCS was instigated by Dr Sigston who raised concerns about an increase in mortality as well as functionality issues with the clinical team.

The Trust initially suspended operations in December 2012 following the unexpected deaths of two patients on consecutive days. On investigation it reported a 'good track record' with no deaths in 2011 and the procedure resumed in January 2013.

However, it was again halted following three deaths in February, April and July 2013. The Trust did not consider it appropriate to record these deaths as serious incidents 'as each case had been examined and was not felt to be inappropriate,' the report states.

Dr Sigston added: "We proactively identified issues with our upper GI cancer surgery service in 2013 and took action. Further in-depth investigations have repeatedly confirmed that the issues were confined to this service and to no others within our Trust, and to a particular type of laparoscopic surgery which has been stopped."

Rosemary Coleman whose husband Philip may have died as the result of keyhole surgery at Maidstone Hospital

Rosemary Coleman whose husband Philip may have died as the result of keyhole surgery at Maidstone Hospital

Solicitors Thomson Snell and Passmore said it received inquiries from a further 10 patients and their families after the Kent Messenger broke the story earlier this year.

The company is examining incidents dating back several years, including that of contracts manager Philip Coleman.

The 63-year-old underwent treatment in 2010 and died in August 2011.

His widow Rosemary, who watched him waste away from 14 stone to around eight, said: “He struggled every day. He spent the last year of his life in pain and unable to eat.”

“If we’d known how ill he was, we would have given up work and stayed with him, but we were told he wasn’t.”

The report by the RCS gives details of an anonymous letter from a member of staff to the General Medical Council in May 2011 raising concerns about 'dangerous and unethical practices' in surgery which was forwarded on to Dr Sigston.

All major upper GI operations now take place at Guys and St Thomas' Hospital in London.

  • Any patients who have concerns about past or present treatment can call the Trust on 01622 228775.

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