Jersey General Hospital - Killing of Elizabeth Rourke?

Doesn't anyone think that what has gone on in court in Jersey over the last two weeks merit any comment?

She lost her life needlessly

From what I have read the tragic death of the patient was simply the culmination of a cascade of system failures – of gross management errors.

Neither the patient nor the locum should have been placed in the circumstances which surrounded the incident.

Will hospital management take the blame?

I very much doubt it...

AN internal investigation will continue into the death of a staff nurse at the Hospital following last night’s not guilty verdict in the manslaughter trial of a consultant.
Dr Dolores Moyano Ontiveros was acquitted of the charge of causing the death of Elizabeth Rourke during a routine operation in October.
However, confusion still surrounds the fact that leading gynaecologist John Day was not called as a witness in the trial. His decision to leave Dr Moyano to operate on her own that day came under sustained attack during the three-week trial.
But neither the prosecution nor defence teams offered him the chance to give evidence – which even bemused UK judge Sir Richard Tucker, who, in the absence of the Assize jury, expressed his surprise that Mr Day was not giving evidence. Dr Moyano did not take the stand either.
Yesterday the jury of nine men and three women took four hours to reach their verdict. During the trial surgeons said that they had battled for hours to save Mrs Rourke, who suffered catastrophic internal bleeding after her main vein was cut and her womb perforated during the initial operation.
The Hospital’s chief executive, Mike Pollard, said that an internal investigation into the incident would continue now the trial was completed. He added: ‘We plan to make public the key findings and recommendations of this investigation in due course. Patient care is always of paramount importance and we are never complacent.’ (from BBC News)

GD - thanks for that, I think there are lots of anomalies about this, particularly why Mr Day was not called as a witness in the trial. It seems that they did not want to find out the truth of the matter. The Jersey H&SS are going to conduct an external investigation - but this will not be subject to any rigorous cross examination of the facts. If true to form it will reflect what the Jersey establishment and in particular the management of the health service want it to say.

sorry shafted i had not read any of what had happened until now.surely this is gross negligence on the part of the hospital.was the locum fully qualified to perform the op.why did the head gynaecologist not operate himself.it does seem strange he was called as a witness at the trial.could it be the establishment sticking together on this.i feel sorry for the family of elizabeth rourke.

A Jersey consultant remains excluded from duties on full pay following the death of a patient in 2006.

John Day was responsible for surgery on the day Elizabeth Rourke died during a routine operation.

Dr Dolores Moyano Ontiveros, who was working as a locum in Jersey at the time, was found not guilty on Tuesday of the manslaughter of Ms Rourke.

Jersey States said Mr Day would remain on leave until reviews of the case were completed by UK and Jersey authorities.

Health and Social Services chief executive Mike Pollard said the internal review was put on hold during the trial and would resume next week, with all the results made public.

He said: "If we have the opportunity to learn anything positive and constructive from this trial and its verdict, then we are keen to do so."

During the three-week trial at the Royal Court, the prosecution claimed Dr Ontiveros was grossly negligent and breached her duty of care to nurse Mrs Rourke.

The defence said Dr Ontiveros made an error of judgement when she operated unsupervised and hit a vein, but it was not a criminal act. (BBC News)

Thistle, the locum doctor, who since the incident has regularly been described as a 'junior doctor' in the press and uncorrected by the health service - thus inferring that she should be working under supervision - was in fact registered with the General Medical Council on their specialist register - meaning that she was qualified to Consultant level. In fact she was on the consultant duty rota for several weeks before the incident which meant she was the only on call senior doctor for any obstetric or gynaecological emergency that came into the Jersey hospital. (see Stuart Syvret's blog and comments for more information)

If as the management seem to want to suggest she was incompetent and should have been supervised - surely they are to blame for allowing her to take such a huge responsibility.

THE Island’s former Health Minister claims that he tried to stop the Hospital manslaughter trial from going ahead on five occasions.
Senator Stuart Syvret says that he approached both lawyers, the police, the Attorney General and the Bailiff to ask them to save Dr Dolores Moyano Ontiveros from having to face trial because of ‘catastrophic failings’ in the Hospital’s management system.
He said that Hospital chiefs pointed the police towards prosecuting Dr Moyano in order to cover up their own mistakes in the appointment, management and subsequent investigation of the doctor.
He even offered to appear in court himself on behalf of Health as he believed that the charge should have been corporate manslaughter against the Hospital.(from thisisjersey)

shafted wrote:Thistle, the locum doctor, who since the incident has regularly been described as a 'junior doctor' in the press and uncorrected by the health service - thus inferring that she should be working under supervision - was in fact registered with the General Medical Council on their specialist register - meaning that she was qualified to Consultant level. In fact she was on the consultant duty rota for several weeks before the incident which meant she was the only on call senior doctor for any obstetric or gynaecological emergency that came into the Jersey hospital. (see Stuart Syvret's blog and comments for more information)

If as the management seem to want to suggest she was incompetent and should have been supervised - surely they are to blame for allowing her to take such a huge responsibility.

The whole thing stinks, but I am sorry if the locum was not good enough for the job she should on never took on the operation, no matter what

She is as much to blame as the establishment!

Suggest you look at http://gilblackwood.com/Satyagraha/seniororjunior.html for some inside information about this case.

Seems like Stuart Syvret may also have managed to persuade the JEP to publish the truth for a change and it may be worth buying tomorrows paper.

For the health and safety of the people of Jersey I certainly hope so,

Phil, I think we know the answer to that, Senator Perchard probably never had sight of the incident reports, and even if he did, he's a farmer that left school at 15, what would he know about the intricacies of surgical procedures.

No No the written statement was almost certainly written by Mike Pollard the give away sign is the term is 'it will come as no surprise to members' pure Pollardism.

Sharpe didn't do a particularly good job though as the truth of what happened in Mrs Rourke's death did not come to light during the trial which seemed happy to place the blame on someone who was never called as a witness by either side. My guess is that is because he knew what really happened and the last thing that the health service wants is the truth to come out. What has the prosecution advocate to do with the hospital? Well just look at who his boss is, none other than the attorney general who is the brother in law of the Bailiff who absolutely wants no more criticism about failures in public service in Jersey to reach the national press. Damage limitation is the name of the game.

Perhaps the inquest will shed more light on this although as it will be conducted by the Jersey judiciary I somehow doubt it.

Not much comfort for Mrs Rourke' s family sadly.

Perchard is on record as saying that he has read the incident reports.
The fundamental point concerning the two incident reports is as follows:
On the basis of the reports Dr M should have been restricted from performing that fatal operation.
Management failed to act according to clearly defined procedure with regard to the two
incident reports and for this reason the Health Dept. should face a
corporate manslaughter charge.