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13th January 2012

Patient died after surgeon removed the wrong organ

A pensioner died on the operating theatre in a South Wales hospital after a surgeon tried to remove the wrong organ during a keyhole operation.

Amy Joy Francis, 77, was admitted to the Royal Gwent Hospital on the 21st July 2010 for the removal of her right kidney which was cancerous.

The first part of the operation was undertaken by a trainee and was uneventful. Problems arose when consultant urologist Adam Carter took over for the removal of the kidney.

Because a camera could not be used in the cavity created Dr Carter was dependant on what he could feel inside the small keyhole incision. Dr Cater felt what he believed to be the right kidney and pulled down sharply, which is normal procedure for the removal of an organ.

Liver was torn in error

Mrs Francis’ blood pressure plummeted and it was immediately evident that Dr Carter had pulled on the wrong organ and torn the liver. It is possible that a hole in the peritoneal membrane had formed which would have caused the liver to become more accessible.

Two senior surgeons were called into theatre, but despite their combined efforts Mrs Francis died of internal bleeding and heart trauma.

A full investigation was undertaken following the death of Mrs Francis and subsequently Dr Cater shared his experiences with colleagues nationwide.

Cathryn Davies, a solicitor at Thompsons Solicitors’ Clinical Negligence Unit said: “Keyhole surgery can be relatively straightforward or it can be technically difficult. In some instances surgeons convert to traditional open surgery to avoid errors such as this where though the operation is keyhole there is no camera to guide the surgeon. Reassuringly the problems encountered in Mrs Francis’ operation have been shared so that lessons can be learnt”.

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