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A narrative verdict has been reached during an inquest into the death of 72 year old Halesowen resident, Peter Brookes. The coroner confirmed that Mr Brookes died after receiving open heart surgery at Queen Elizabeth Hospital, carried out by Mr Ian Wilson.
The coroner concluded that unnecessary procedures led to an increased operation time which contributed to Mr Brookes' death. The Court heard from an independent expert that non-essential procedures added to the already lengthy operation time by 40 minutes and caused more harm, damaging Mr Brookes' heart, triggering low blood pressure and cardiac arrest. Lack of circulation led to a brain injury from which Mr Brookes did not recover.
Mr Brookes, attended University Hospital Birmingham NHS Foundation Trust (UHBFT), Birmingham, for a triple heart bypass operation on 2 September 2011. Nearly double the surgery needed took place, resulting in six bypass grafts, mitral valve repair and an aortic valve replacement.
The operation was carried out by cardiothoracic surgeon Mr Ian Wilson, who undertook more surgery than was required during the procedure. He later entered important timings concerning the operation on a database, which differed from those recorded by other medical professionals present during the surgery.
Mr Brookes never regained consciousness and died in intensive care on 15 September. Lack of oxygen to his brain after prolonged surgery, low blood pressure and repeated cardiac arrests, were the main cause.
Mr Brookes was among 15 of Mr Wilson's patients reported to have died between September 2011 and September 2012, prompting an investigation by the UHBFT where he worked.
This led to a wider investigation which identified Mr Wilson had incorrectly entered patient risk factors into a national database impacting on his overall anticipated mortality rate. The Coroner found that, had Mr Wilson not done so, UHBFT would have intervened earlier and he probably would not have carried out Mr Brookes' operation.
Mr Brookes' wife, Margaret, said:
'We are thankful that the Queen Elizabeth Hospital has systems in place to monitor surgeons' patient mortality rates. It was only because of this monitoring that the subsequent investigation took place and the risks and falsification of records came to light. That said, we have recently discovered that the falsification of data goes back to 2003 – far longer than originally suspected. If that had been discovered sooner then my husband would most likely still be here today.'
The UHBFT summarily dismissed Mr Wilson, however under a GMC Interim Order he is allowed to practice with a number of employment conditions.
'We are concerned that Mr Wilson is employed at New Cross Hospital in Wolverhampton, and we understand that they have not obtained an employment reference from the UHBFT. We have no idea how long it will take for the GMC to finish the investigations into his fitness to practice as a surgeon, but we hope that they deal with the case quickly and efficiently in order to protect patient safety.'
'The coroner concluded the case with a narrative verdict, which outlined that unnecessary procedures prolonged the operation, which subsequently damaged Mr Brookes' heart.'
'Missed opportunities to identify problems and accurately record patient data by Mr Wilson resulted in a very tragic case. It is still not clear how many other of his patients were harmed by his practices.'