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October 13, 2024
Surgeons operating on pregnant women should have “the necessary levels of skills and expertise to perform the operation safely”, the Royal College of Surgeons has said, after a pregnant woman died when trainee doctors removed her ovary instead of her appendix.
The recommendation was made following an inquest inquest into the death of Maria De Jesus.
The mother-of-three died at Queen’s Hospital, Romford, on November 11, 2011, after trainee surgeons removed her ovary instead of her appendix.
Clare Marx, consultant surgeon and lead for patient safety at the Royal College of Surgeons said: “Each case should be discussed with the consultant supervisor prior to surgery whose responsibility it is to assess that the trainee has the required level of expertise and experience to perform the operation to a high standard.”
Miss Marx, who works as an orthopaedic surgeon at Ipswich Hospital NHS Trust added: “Operating on patients that are pregnant is known to carry additional difficulties and risk, therefore it is extremely important that the surgeon has the necessarily levels of experience and expertise to perform the operation safely and to a high standard.”
Mrs De Jesus, of Wroxall Road, Dagenham, was five months pregnant when she was admitted to the hospital on October 21, 2011 complaining of abdominal pain, an inquest earlier this month heard.
She was diagnosed with appendicitis and an operation was arranged to remove the appendix on October 23.
But the two trainee surgeons who carried out the procedure in the absence of a consultant surgeon removed a healthy ovary believing it was an appendix.
The General Council’s Good Medical Practice Guide also states that doctors “must ensure that all staff they manage have appropriate supervision”.
Eight days after the operation Mrs De Jesus was discharged from the hospital but she admitted herself on November 7 when her stomach pains got worse.
Doctors only picked up on the mistake on November 9 – two weeks after the operation.
The histopathology report, which would have revealed the error, had been available since October 31 but was not checked my doctors.
The day after the discovery was made 110 mls of pus produced by the diseased appendix, was drained from Mrs De Juses’s abdomen.
Despite attempts to save her, she miscarried and died on the operating table during the second attempt to remove the appendix.
Averil Dongworth, chief executive of the Barking, Havering and Redbridge Hospital Trust (BHR) said that “she fully accepts the inquest verdict” and apologised to the family.
Since the death, the hospital has implemented a recommendation that trainee surgeons will never be able to operate unsupervised on pregnant women again.
Source London24