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Death Through The Keyhole - The Surgical Experiments of
Mr Andrew William Hall FRCS, Consultant Surgeon, Glenfield Hospital,
Leicester Updated 9th Oct 2008 See the following exerpts from coverage in the Sunday Mercury
You can comment on this story at the NHS Exposed Blog. Written in memory of Mrs Beryl Walters Introduction Ms Susan Walters is an admirable woman. Since her mother's tragic death in July 1998, she has fought tirelessly to extract the truth about her death from Leicestershire's Glenfield Hospital. Now, after more than five years of tears, devastation, dedication, determination, courage and extremely hard work, the Health Ombudsman has upheld a number of extremely serious complaints against Mr Andrew William Hall, the Consultant Surgeon who operated on her mother. When I asked Sue how she had managed to achieve this resounding victory for truth and justice, she said, "In order to find the truth about the death of my Mum, Beryl Walters, in 1998 at Glenfield Hopsital the following were required:- Educational level MA, Computer and internet skills, 20 hours per day free time, enough money to make 50 telephone calls a day, £8,000 to retain a lawyer, Letter writing skills, Time to visit MP, English Language to a very high level, 1st year law degree, Ability to research to a high level, Ability to read and comprehend medical terms and jargon and lots of courage, determination and love". When the authorities largely ignored her initial complaints, Sue refused to give up. Instead, she persevered in the face of Glenfield Hospital's attempts to protect Mr Hall, beginning a law degree and undertaking the background research necessary to debunk the hospital's whitewash explanations. She complained to the General Medical Council and discovered, as have many others before her, that the GMC is incapable of protecting the public from a surgeon who tries out experimental techniques without the patients' consent. That Sue has succeeded so brilliantly in her quest for justice comes as no surprise to me. She was one of the few generous souls who, in the year 2000, followed me to London to take part in a protest against human rights violations in the NHS. One of our clearest memories of the day is the overwhelming indifference exhibited by the Department of Health towards the few patients who wanted to register a protest there. Rather than listen to their grievances, the Department of Health literally closed their doors on us. Not content with refusing to hear us themselves, it seems that the DoH were determined that nobody else would hear us either; a large number of journalists from all the major newspapers attended the protest, taking photographs and interviewing the protesters, yet the protest received very little publicity. Much later, some of the attendant journalists told us that their editors had banned any coverage of the event. Apparently, the government's spin machine was at least as effective as the post-Campbell media reports suggest! Nonetheless, many of us continued with our campaigns for a more accountable Health Service, Sue Walters amongst us. It is this spirit of determination, this refusal to be fobbed off with placatory untruths that has gained Sue the victory that she and her family deserve. We examine the recent decision from the NHS Ombudsman. Click here for the full report in MS Word format. Background
In May 1998, Mrs Walters was diagnosed as suffering from the early stages of oesophageal cancer. Although she had been an insulin-dependent diabetic for some 55 years, she was in otherwise reasonable health, and, at 67 years of age, was considerably younger than many patients in whom this condition is discovered.
The operation, which involves detaching the stomach from its connections in the abdomen, opening the chest to detach the tumour and oesophagus from their connections there and then removing them before joining the stomach to the remaining part of the oesophagus in the neck, is normally expected to take approximately six hours. It is, however, a well understood, well documented and frequently performed procedure, with clearly defined criteria for determining whether or not it is an advisable option for any given patient. As such, the inevitable risks associated with such an extensive invasive procedure are probably as acceptably low in a three-stage oesophagectomy as could reasonably be expected of any complex operation.
On the evening of Sunday, the 21st June 1998, a fifteen-minute meeting took place between Mr Hall and Mr and Mrs Walters. At this meeting, Mr Hall announced that he no longer intended to carry out the planned three-stage oesophagectomy that he had previously recommended. Instead, he wished to use a laparoscopically assisted mobilisation of the stomach and lower oesophagus, coupled with a mobilisation of the upper oesophagus via a neck incision in order to avoid opening Mrs Walters' chest. Mr Hall claimed that this would be better for Mrs Walters, but did not adequately explain the potential risks involved in this procedure. Nor did he inform Mr and Mrs Walters that, although he was reasonably familiar with laparoscopic procedures in general, this would be the first time that he had employed this exact sequence of interventions, and the first time he had attempted to avoid opening the patient's chest. Never before had he attempted to work his way all the way up from below with the laparoscope in an oesophageal cancer case, or used the laparoscope to improve the view in the neck incision.
The Experiment
Having opened Mrs Walters' chest, Mr Hall discovered that his earlier actions had split her trachea in two places, and he was obliged to call in the consultant thoracic surgeon to effect repairs before he could continue with the planned oesophagectomy. Meanwhile, Mr and Ms Walters were anxiously awaiting Mrs Walters' return to the intensive care unit, and were beginning to suspect that something had gone radically wrong. Mrs Walters was finally returned to the unit some twelve hours after being taken to theatre for what should have been a six-hour operation. Mr Hall refused to discuss matters with her family that evening, instead sending his Senior House Officer to explain the situation and offer them a meeting with Mr Hall the next day. The Aftermath As had been originally expected, Mrs Walters required mechanical ventilation following the operation. However, in the days following her return to the intensive care unit, all attempts to wean her off mechanical ventilation failed. Indeed, far from strengthening, her condition quickly began to deteriorate. Her left lung appeared to have partially collapsed and she was suffering from a temperature and elevated white cell count, although repeated tests to identify any form of chest infection were consistently negative. As her ability to breathe decreased, the drainage bag on Mrs Walters' naso-gastric tube was seen to be filling with air, and required frequent emptying. It was also noted that on occasion her abdomen became seriously distended as it filled with air, and she began to suffer from sever diarrhoea. Mr Hall began, belatedly, to suspect that an abnormal connection between the windpipe and the gullet, known as a tracheo-oesophageal fistula, might be the source of Mrs Walters' ever increasing problems. However, numerous chest X-Rays and several bronchoscopic examinations of the site of the repaired tracheal tears revealed no sign of a fistula, although a CT scan, while not revealing the fistula itself, did show a gas shadow passing behind the trachea at the point at which the stomach had been joined to the remaining upper oesophagus. It also highlighted small collections of air to the left of the trachea outside the line of the intra-thoracic stomach. Even so, Mr Hall was not completely convinced of the existence of a fistula, and was unwilling to seek advice from his colleagues or take any steps to reduce the impact of any fistula that may have been present unless and until he had obtained definite evidence of its existence. To further complicate her worsening condition, it became apparent that Mrs Walters had lost the use of her legs and, subsequently, her arms. An MRI scan, carried out on the 16th July 1998, showed an infarct within the spinal chord that was associated with haemorrhage into it and which had rendered Mrs Walters tetraplegic. Finally, on the 17th July, Mr Hall became sufficiently convinced of the existence of a fistula to urgently seek the opinion of his colleague, Mr Waller, who had sutured the tears in Mrs Walters' trachea. Unfortunately, Mr Waller was on leave from the hospital until the 20th July, and Mr Hall elected to wait for his return, rather than consult the thoracic surgeon who was covering in his absence. By the 21st of July, exactly one month after Mr Hall had announced his intention to abandon the operation that he had so strongly recommended to Mr and Mrs Walters in favour of an experimental, laparoscopically assisted technique that he had never attempted before, Mrs Walters' condition had deteriorated to the extent that all active treatment was withdrawn. She passed away in Glenfield Hospital's intensive care unit at 12.30 PM on the 21st July 1998. Inquiry In examining this tragic chain of events, the Health Service Ombudsman appointed a Consultant Thoracic Surgeon and a Consultant Anaesthetist and Intensivist to act as Professional Assessors and to advise on clinical matters in this case. Evidence was taken from Ms Walters together with various members of the Trust staff including Mr Hall. The Ombudsman's findings make shocking reading. With regard to Mr Hall's choice of procedure, the Professional Assessors said: "we found no convincing evidence as to why the Consultant Surgeon should suddenly change his opinion and opt for what was in 1998, and possibly still remains, a relatively unfamiliar and untested operation to avoid a thoracotomy. … there were no overwhelming medical reasons why a thoracotomy and thus a standard three?stage oesophageal resection procedure could not have been adopted" and the Investigating Officer concluded: "I am not satisfied, on the basis of the Assessors' advice, that the Consultant Surgeon's original plan to perform a three-stage operation on Mrs Walters was in any significant way contra-indicated." Referring to Mr Hall's fifteen-minute meeting with Mr and Mrs Walters on the evening before the operation, the Professional Assessors said: "A discussion of this duration for informed consent immediately prior to surgery, after a previous discussion by the same surgeon concerning the same operation, is perfectly reasonable. However, in our opinion, it is not a reasonable time for a discussion relating to consent if the nature of the proposed surgery is suddenly and significantly changed." and the Investigating Officer concluded: "It is clear the Consultant Surgeon had initially described the surgery as a standard three-stage oesophagectomy, and that the first time the trans-hiatal laparoscopic technique was mentioned was during a brief discussion the night before Mrs Walters' operation. This last minute reference to the laparoscopic procedure was unacceptable, as the Consultant Surgeon accepted at interview. … It is the responsibility of the doctor to provide patients with 'sufficient information in a way that they can understand about the proposed treatments, the possible alternatives and any substantial risks, so that they can make a balanced judgment' (the DoH Guidance). I am critical of the Consultant Surgeon for not ensuring that this occurred in Mrs Walters' case." On the subject of Mr Hall's refusal to communicate with Mr and Ms Walters after the operation, the Investigating Officer concluded: "I accept the Assessors' advice that it was not acceptable for the Consultant Surgeon to delegate the delicate task of talking to the family to the SHO. I uphold this complaint in full." In considering Mr Hall's behaviour with respect to the suspected existence of a tracheo-oesophageal fistula, the Professional Assessors said: "The diagnosis of a post-oesophagectomy tracheo-oesophageal fistula is as much a clinical diagnosis as one established by investigation. … too much weight was given to the apparent absence of a fistula in the investigations, all of which have a false negative rate. Not enough weight was given to the clinical evidence of a tracheo-oesophageal fistula. Once there is reasonable suspicion of a tracheo-oesophageal fistula, some effort to reduce the volume of gastric content passing through the fistula must be made even if it is not felt appropriate to defunction the stomach or to close the tracheo-oesophageal fistula surgically. … Tracheo-oesophageal fistula can be a fatal complication unless treated. It is far more likely to occur in those patients who have an anastomotic leak. Clinically, the presence of a tracheo-oesophageal fistula should have been suspected from 29 June onwards because of the persistence of left lower lobe collapse and the air filling the naso-gastric tube. By 9 July the diagnosis was almost certain on clinical grounds because of an air leak via the naso-gastric tube, gaseous distension of the intestinal tract and free air to the left of the trachea on the thoracic CT scan. … we are critical of the fact that, despite clinical and radiological evidence of a leak on 9 July at the latest, no active treatment plan was established that day or advice sought from a thoracic surgeon. … The Surgical Assessor is of the view that action taken around 29 June, in the form of the placement of a gastrostomy tube to decompress the fistula, may have altered the outcome. There is, however, no guarantee of this. Our criticism is of the failure to consider actively the possibility of a tracheo-oesophageal fistula and to institute appropriate treatment. … " And the Investigating Officer concluded: "… a presumptive diagnosis should have been based upon the clinical signs, which suggested the presence of a fistula. … I accept the Surgical Assessor's view that the tragic outcome might have been avoided had more timely diagnosis of the fistula occurred resulting in treatment being implemented. I do not believe that any explanation for the failure to diagnose the fistula after 9 July could possibly be expected to persuade Ms Walters that Mrs Walters received adequate care. I uphold this complaint. … I share the Assessors' view that, considering how serious Mrs Walters' condition was, the Consultant Surgeon should have consulted with the thoracic (or cardiothoracic) surgeon on call, particularly in light of Mr Walters' concern." The Ombudsman's report makes it clear that Mr Hall did not adequately explain the proposed changes of plan to Mrs Walters, and failed to advise her that, although this was the 11th time he had used an abdominal laparoscopic approach in cancer cases, he had never attempted this precise procedure before. Nor did he inform her that this procedure was not standard practice in the UK at that time. Mr Hall himself was not present when Mrs Walters was asked to sign the consent form, having sent a Senior House Officer to obtain consent instead. When asked, at the time, if he considered the procedure to be experimental, he replied that the techniques were routinely used in his everyday practice, and that all he was doing was to perform a conventional operation slightly differently. In consequence, the report points out that Mr Hall did not ensure that Mrs Walters had sufficient information to make an informed judgement as to whether or not she wanted to continue with the operation in light of the changes in plan. This becomes particularly significant when viewed in the context of the final, catastrophic outcome of this operation. Both the Investigating Officer and the Professional Assessors were emphatic that Mr Hall should have considered the possibility of a tracheo-oesophageal fistula much earlier than he did, and taken appropriate action based upon that possibility rather than awaiting direct confirmation of his suspicions. Had he done so, it is possible that Mrs Walters' untimely death could have been avoided. His failure to do so, leading to Mrs Walters' death as the result of a botched experimental operation to which she was not given the proper opportunity to consent is, in the opinion of NHS Exposed, entirely inexcusable. Yet even this needless waste of a human life, due solely to the wrong surgical decisions made by a reputedly very competent surgeon, may not be the full extent of Mr Hall's apparent misdeeds. Suspicions Dr Leverment, another cardio-thoracic surgeon from Glenfield, is alleged to have spoken with Susan Walters about her mother's case. He is reported to have told her that, "[Dr Hall] should NOT be doing these operations. The lid wants blowing off what's going on at Glenfield. If I had been called I could have saved your mum. What happened to your mum was disgusting." Furthermore, NHS Exposed is given to understand that, even before the fiasco surrounding Mr Hall's failed experiment involving Mrs Walters, at least one of his former patients had taken steps to instruct solicitors in a matter involving Glenfield Hospital NHS Trust, Mr Hall and yet another controversial laparoscopically assisted operation. Clearly, therefore, Mr Hall's antics had been the subject of considerable concern for quite some time. Yet his background is that of a respected senior surgeon. The GMC Mr Andrew William Hall, who qualified from Liverpool University in 1968, teaches a course in "Endoscopic Suturing Techniques" at the Royal College of Surgeons, and also holds a private post with Nuffield Hospitals in Leicester, where he specialises in General Surgery. His General Medical Council registration number is 1212996 and, according to the Council he is entitled to hold a post at any Grade, "including honorary, substantive or fixed term consultant in the NHS. Confirmation of a doctor's eligibility to work in general practice must be obtained separately from the JCPTGP or, in the case of an EEA doctor, the GMC. Start Date: 13/08/1996." Unfortunately, the GMC's publicly accessible records make no mention of the fact that, in December 2000, Mr Hall was issued with a warning letter as a result of a complaint brought against him by Mr Walters. This letter - effectively a minor slap on the wrist - reminded Mr Hall of the standards of professional conduct expected of doctors by the Council. In particular, it focussed on the consent issues raised by Mrs Walters' case, but was careful to reassure Mr Hall that the GMC's Preliminary Proceedings Committee felt that the level of care he had provided to Mrs Walters was reasonable. To view the GMC's letter of explanation to Mr Walters, including the text of the warning sent to Mr Hall, click on the thumbnail images below.
That the GMC's comments are in stark contrast to the Health Service Ombudsman's damning findings heaps yet more doubt upon the GMC's ability to carry out its designated function of protecting patients. Despite the Ombudsman's clearly stated view that Mrs Walters could have been alive today if only Mr Hall had paid attention to the clinical data available to him, the General Medical Council, upon consideration of broadly similar information, concluded that Mr Hall had performed adequately and was safe to work in the NHS. Plainly, the Council felt no need to conduct "discreet" inquiries into Mr Hall's background, as they have done in other cases with much less justification. The GMC's treatment of Mr Hall also compares poorly with its treatment of Consultant Surgeon Mr Robert Phipps. After raising concerns about negligent surgical practices at Bradford Royal Infirmary, Mr Phipps became the subject of a GMC investigation that has so far lasted for several years. Yet, far from having performed an experimental operation on a patient without properly obtaining her consent, and then overlooking blatantly obvious indications that could have saved her life, Mr Phipps' alleged misdeeds feature easily explained discrepancies on his CV that are now approximately 20 years old. That Mr Phipps has recently won an Employment Tribunal against those who complained about him seems to hold little interest for the GMC; clearly, his 20-year-old CV is a matter that falls within its capabilities while the horrifying, needless death of a patient is simply beyond its ability to handle. If further evidence were needed in support of this contention, the GMC were quick to issue an alert letter concerning Mr Phipps. Yet no similar alert letter was issued in Mr Hall's case. These comparators clearly show the manner in which the GMC behaves towards doctors that have incurred its wrath - perhaps by drawing unwelcome attention to serious deficiencies within the medical profession. Mr Phipps' life has been made impossible after he raised concerns about patient care, while Mr Hall prospers despite the events of recent years. Review Whatever the truth of these speculations, the Health Service Ombudsman has made it clear that Mr Hall's actions cost Mrs Walters her life and ruined the lives of her family. It is little consolation that, in April 2002, the President of the Association of Upper Gastrointestinal Surgeons told Ms Walters that, in their view, procedures such as that carried out on Mrs Walters should only be undertaken after full local ethical committee approval. Mr Hall agreed not to perform any more such operations unless under clinical trial conditions, but this is scant compensation for those who suffered at his hands. Indeed, he has always maintained that he only ever intended to carry out 12 such procedures, of which Mrs Walters' operation was to be the 11th, before stopping to review his results. It took Susan Walters and her father three years to force an independent review of the case. They were running out of time in which to take legal action, so their lawyer advised them to accept a payment of £8,000 and accept that liability would not be admitted. Although this is a paltry sum in comparison to the value of Beryl Walter's life, the family at least felt they had been vindicated to some extent. Unrepentant But, if Mr Hall did indeed take it upon himself, between 1992 and 2000, to conduct 12 experimental operations, who knows what might have befallen the patients whose names we cannot establish? The GMC says it cannot release case notes of a particular surgeon, giving, rightly or wrongly, the impression that once again the medical profession is closing ranks around a colleague in distress. Mr Hall claimed, at every opportunity, that he was only ever acting, surgically, in what he considered to be the best interests of the patient. Indeed, even during the Ombudsman's investigation, he continued to assert that he would not have devised a care plan for Mrs Walters' suspected tracheo-oesophageal fistula that was based on clinical evidence. Of this stubborn attitude, the Investigating officer said: "I also remain concerned that the Consultant Surgeon did not appear at interview to have reconsidered his orientation to Mrs Walters' problems in ICU, whereby clear clinical signs were not acted upon." The Future Susan Walters feels, quite rightly in our view, that the story should not be allowed to rest as it is, and hopes that the Crown Prosecution Service will deem her case worthy of action by the police. Her father, sadly, is no longer with us, and will never now find the satisfaction of seeing a proper conclusion to the tragic case of his beloved wife Beryl. Ironically, it appears that Mr Hall was successful in removing the cancer. Had the catalogue of post-operative errors been avoided, it is entirely likely that Mrs Walters would have been alive today. Speaking of her long campaign for justice, Sue told us "My mum was a very special lady. If this whole disgusting affair had happened to me then she would have done the same for me. 'Evil prospers when good men do nothing' … In this country where 1 in 3 cannot read to a high level, a proportion of the population speak English as a second language, many can't afford a computer or computer training, many struggle to make ends meet.... what are their chances of demanding the truth? And what of the grief, the loss? Coping with depression and isolation? Very rarely will the lamb slaughter the butcher". Her words ring true for many people. Unfortunately, that is the day-to-day experience of anyone who seeks the truth. They require dedication, determination and above all the courage to continue when the doors shut in their face. We have all been there - the journey is long, extremely hard, filled with tears and devastation. In the end, Ms Susan Walters picked herself up, wiped her tears away and carried on with the belief that one day justice would prevail. This wasn't about bereavement or emotion - this was about defeating an arrogant surgeon at his own game. It was about protecting others from him. It was about never allowing another person to die in the way Beryl had done. Susan has been a driven lady - educated and armed herself with everything we all require to challenge the authorities. Emotion has converted itself into cold hard logic, and the success of her powerful arguments speaks for itself. You can comment on this story at the NHS Exposed Blog. Resources Laparoscopic Intestinal Surgery Laparoscopy Surgery from Patients UK Definitions of Laparoscopic Surgery Shutting Down a Whistleblower -Mr Robert Phipps Sacked surgeon is hit by double blow Cancer hospital whistleblower claims £170,000 `I got sack for voicing fears over patients' Surgeon `unfairly sacked' says tribunal
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Losing
a parent has to be one of life's most traumatic experiences, but for
Ms Susan Walters the circumstances surrounding the death of her
mother, Beryl, were especially hard to accept. Her long and courageous
campaign for justice has led the Health Service Ombudsman to this week
publish a damning report into the appalling treatment and needless
death of Mrs Beryl Walters, following an experimental operation
performed by a consultant surgeon at Leicestershire's Glenfield
Hospital Surgical Unit.
On
the 19th May 1998, Mrs Walters, together with her husband, discussed
her situation in clinic with consultant surgeon Mr Andrew Hall.
Several options were considered, including the possibility of doing
nothing at all. Because of the early stage at which the cancer had
been identified, it was felt that Mrs Walters would probably live for
a long time even if nothing were to be done. However, if she were to
undergo a three-stage oesophagectomy operation, it was felt that her
chances of making a full recovery were extremely good.
After
some consideration, Mrs Walters decided to go ahead with the
operation, and she was admitted to Glenfield Hospital on Friday, 19th
June 1998. Her admission notes show that she was generally fit and
well at that time, and was experiencing no breathing difficulties. The
operation was scheduled to take place on the following Monday, the
22nd June 1998.
Unaware
of the highly experimental nature of the operation that she was about
to undergo, Mrs Walters signed the consent form that the Mr Hall's
Senior House Officer presented to her the following morning, and was
taken to theatre shortly afterwards.
Once
there, the first stage of Mr Hall's experiment on Mrs Walters - the
laparoscopically assisted mobilisation of the stomach and lower
oesophagus - was apparently completed with some degree of success.
However, the second stage - the mobilisation of the upper oesophagus
via a neck incision - quickly ran into difficulties. Despite further
use of the laparoscope in an attempt to improve his view, Mr Hall was
unable to successfully mobilise the upper oesophagus, and was left
with no alternative other than to open Mrs Walters' chest and proceed
according to his original plan, having first closed the abdominal
incision that his failed experiment had required.)
)
