Lack of a ventilator following a routine knee operation is the latest in a series of scandals
The brother of a woman who died after routine treatment at an NHS surgical clinic run by a building firm has called for the centre to be closed after an investigation found that, at a crucial moment, it did not have a ventilator available.
Anita Mansi, who was 86, died last summer from multiple organ failure two days after a knee operation at the controversial Surgicentre, an NHS service in Hertfordshire run by Carillion, formerly part of Tarmac. She had previously been in good health. Hers was one of three deaths that prompted an independent investigation before Christmas into the care of four patients, including one who survived treatment at the Surgicentre.
The firm has been urged by the investigator to consider how staff react when a patient’s health deteriorates; to address the training of medical staff who have to deal with post-operative complications; and whether staff were able to easily access medical records held by the neighbouring NHS Lister hospital.
The Lister hospital in Stevenage, to which Mansi and other patients who died were transferred after treatment at the Surgicentre, was also asked to consider a series of issues around its care.
However, the Observer can reveal that the report also contained the admission that nurses dealing with the case at the privately run centre had needed a ventilator at 8.30am the day before the patient died, but “no machine was available”. That admission, along with the report’s further revelation that clinical medical records are missing and that the resident medical officer at the Surgicentre did not ask for a more senior doctor to attend to Ms Mansi as her health deteriorated, has provoked her brother, Michael, to demand the closure of the centre, which has been at the centre of a series of scandals over the past year.
It has already been investigated over potential failings in the cases of six patients who suffered irreversible sight loss after treatment. Local doctors are advising patients against having procedures done at the centre, where there have been 21 serious clinical and patient information incidents since the clinic opened in September 2011. The clinic also lost the records of 8,500 ophthalmology outpatients last year, prompting local MP Stephen McPartland to back calls for Carillion to lose its licence.
Speaking to the Observer, Mr Mansi, 76, added his voice to demands for the centre to close. He said: “After the operation, when I visited her in the centre, she appeared well. She stumbled over her words at one point, but was talking about cooking Sunday lunch that weekend when she was to be discharged. Then she dies within 48 hours.
“The independent investigator’s report clearly says there wasn’t a ventilator when it was needed. The staff also don’t appear to have called in a senior doctor as her health deteriorated, but took advice by phone. And there are clinical records missing. I want the centre shut down so that no one else can be treated there only to end up in a box.”
The independent report for NHS Hertfordshire, by Dr Alan Fletcher, concluded that Ms Mansi’s care was “satisfactory” overall. It said it was easy to find fault in “detailed reviews of such cases” and that overall the treatment patients received was not “substantially different to that provided to many, many patients in the UK in similar circumstances”.
However, it noted that the need for a ventilator on the morning before Ms Mansi died was frustrated because there was “no machine available”.
Mr Mansi said it had been a struggle for him to get to the truth about his sister’s death. “They say they will learn lessons. I am sick of the cliches. This was Anita’s first time at the centre and I do not believe she should have died.”
Mark O’Flynn, medical director for Lister Surgicentre, said: “Dr Fletcher makes recommendations about the speed of response when specialist care is needed. This was identified by our own investigation and action. This means that if our clinical teams have concerns about the speed of response they more quickly escalate it to a senior manager.
“We have also made a number of other changes. These include changes to patient records to make it easier to identify entries by different health professionals and have also increased, with the support of East & North Hertfordshire NHS Trust, the post-operative input from the clinical team that undertook the patients’ surgery.
“Having received the review we are making sure that there are not any other lessons that we can learn. We would like to extend our condolences to the families concerned and recognise the additional anxiety that has been caused due to the media’s interest.”
An NHS Hertfordshire statement said: “The review did make some recommendations and includes the requirement for more clinical supervision for medical staff, better access to full medical records between the Surgicentre and the Lister Hospital and clearer arrangements for access to senior medical and surgical review of patients at Surgicentre.”