2 days ago
The hospital where routine heart operations became a death sentence
Dorothy Readhead was hoping an innovative heart operation to replace a faulty valve would give her a new lease of life – but it turned out to be fatal.
The 87-year-old was suffering from breathlessness, but was not suitable for open-heart surgery.
A new, less invasive procedure to replace the aortic valve – called a transcatheter aortic valve implant (TAVI) – promised her a return to gardening and helping out at her local church.
But doctors at Castle Hill Hospital, near Hull, botched the procedure after trying to force the new valve through the wrong leg, causing a major artery tear and the loss of five litres of blood during a six-hour operation.
Mrs Readhead died a week later, in the summer of 2020, with her family none the wiser about what had occurred.
Now, it has been revealed that a catalogue of surgical errors, doctor in-fighting and omissions from death certificates has led police to investigate the deaths of 11 patients who had the same procedure at Castle Hill's cardiology department between 2019 and 2023.
Documents seen by The Telegraph reveal how 'a rolling power struggle' between consultants charged with running the cardiac unit distracted from caring for patients, while hospital executives alleged that doctors' abuse of the whistleblowing system had been a 'weapon of mass destruction that has harmed patients'.
All of the 11 patients were having a TAVI installed. It involves doctors replacing a damaged valve by accessing an artery, often in the upper leg, and feeding a new valve through a wire all the way to the heart, where it will sit inside the old valve and restore normal function.
At Castle Hill, operated by the NHS Humber Health Care Partnership, the mortality rate for the procedure was three times higher than the national average, according to the BBC.
Meanwhile, one of two independent reviews by the Royal College of Physicians (RCP) into the deaths raised serious concerns about death certificates failing to acknowledge the surgeries as a contributing factor, leaving families in the dark, the broadcaster said.
In the case of Mrs Readhead, she had blockages in her right leg caused by calcified arteries that made it unsuitable for access.
Despite this, surgeons went in through the right leg by mistake. Then, after realising their error, they failed to change tack and instead tried to plough through the blockage three times, eventually causing a major tear of the femoral artery.
By this point, Mrs Readhead had been on the operating table for six hours and had lost five litres of blood.
She died a week later, with her death certificate failing to declare the operation as a cause. Instead, it cited 'hospital acquired pneumonia' and 'severe aortic stenosis' –- the condition the operation was supposed to treat.
Christine Rymer, Mrs Readhead's daughter, only found out what her mother had endured after being approached by the BBC. She said: 'None of that was told to us. None of it. It just feels as if Mum was a guinea pig, which is not nice to think about.'
Mrs Readhead's care was 'graded poor' by the RCP in its 2021 report because of the use of an 'inappropriate access site' during a procedure. It said this 'unfortunately resulted in an avoidable vascular complication'.
An anaesthetist called in to help during the operation wrote in an email that the TAVI team's decisions had 'resulted in a disaster for this patient'. He said there was 'a change of plan without weighing the risks vs benefit for the patient, but having a 'have a go' approach'.
Dr Thanjavur Bragadeesh, the then clinical director of the cardiac unit, called for a serious incident to be declared so there would be a full investigation into the case, which there later was.
He was one of seven consultants who wrote a letter to Chris Long, the hospital's chief executive, and Dr Makani Purva, the medical director, saying they were 'very concerned about the safety and transparency of the TAVI service'.
Dr Bragadeesh was later removed from his position as part of a restructuring of the unit's management, and would take the trust to an employment tribunal.
He argued he had raised concerns around four deaths, but the tribunal ruled against him, saying 26 of 29 complaints had not been made within the required three-month time frame.
Documents from the hearing reviewed by The Telegraph reveal an email written by Dr Simon Thackray, who was associate medical director at Hull Teaching Hospitals at the time, in which he said: 'A rolling power struggle between key individuals has dragged in much of the time and energy that normally individuals would put into service development.'
He said: 'A huge amount of time has been spent investigating retaliatory complaints, dealing with rudeness and incivility, and trying to bring a sense of direction to teams pulling in opposing directions.'
And he added that disclosures about colleagues' wrongdoings and errors were 'a weapon of mass destruction that have harmed patient care in my department to further personal grievances'.
It also revealed that Dr Purva sought advice from the General Medical Council (GMC) about the behaviour of the doctors.
'In a further twist to the long-standing issues between 2 cardiologists, one of them has accused the other of taking away one of his patients and offering him a different treatment option which caused his death,' she wrote.
In another case, Brian Hunter, a former fisherman from Grimsby, was diagnosed with a heart problem at 83 and offered a TAVI procedure.
The RCP's second review found 'a lack of urgency' to treat him so by October 2021, when the operation took place, he was 'a high-risk case… with an increased risk of complication and little margin for error'.
Medics failed to properly deploy the device, allowing blood to leak back into the hear, and he died on the operating table.
'We were led to believe that dad had a heart attack on the table and unfortunately passed away,' Tracy Fisher, Mr Hunter's daughter, told the BBC. 'To find out three years down the line that what your father actually passed from wasn't the truth is torturous.
'I feel angry as well, and so does the rest of the family, that [the hospital] just outrageously lied. At no point do any of us find it acceptable. It's just not.'
The RCP also highlighted serious concerns about the failure to put the failed surgeries on death certificates.
The death certificate of a 73-year-old man who had the valve implanted in the wrong position also failed to contain 'an accurate description' of what happened. An initial version that included 'failed TAVI' was amended to just state 'pneumonia'.
In two other cases, women who died within six weeks of each other had crucial details missing from their death certificates, making them inaccurate, the RCP said.
A spokesman for Humberside Police said: 'An investigation is in the very early stages in relation to deaths following TAVI surgery at Castle Hill Hospital. Inquiries are being carried out and at this time, we can confirm no arrests have been made.'
A spokesman for NHS Humber Health Partnership said: 'We would never discuss an individual patient case in the public domain, but we understand families may have questions and we are happy to answer those directly.
'We have previously written to families who have lost a loved one following TAVI treatment with an invitation to meet and discuss the specific circumstances of their case, and we would reiterate that offer.'
They added that the service has the confidence of regulators and claimed that external reviews had 'shown that mortality rates associated with TAVI are similar to national mortality rates over a four-year period'.
The spokesman said: 'The Royal College of Physicians was invited to review the service in 2021, at the request of the Trust's chief medical officer. The Royal College report concluded that the TAVI service is essential for the Humber and North Yorkshire region and needs to be expanded.
'It stated however that the design of the service should be reviewed and invested in. The report offered a number of actions for improvement and we have delivered against all of those since it was shared with us.
'A key improvement has been the dramatic reduction in the length of time patients wait to have their TAVI procedure, which was shown in the Royal College Report to have been too long, like many other TAVI services across England.'
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