Surgeons removed wrong kidney in 'catastrophic error'

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Two "grossly negligent" surgeons removed a patient's only healthy kidney in an "appalling" catastrophe which led to his death, the General Medical Council (GMC) was told yesterday.

Graham Reeves, a 69-year-old Korean war veteran, died five weeks after an operation in which his left kidney was taken out instead of his chronically diseased right one.

John Roberts, 61, the head of the urology department who supervised the procedure, yesterday admitted all but one of the factual charges against him while denying serious professional misconduct.

Mahesh Goel, 41, the registrar who removed the kidney, also denies serious misconduct while admitting a number of the charges. Leighton Davies QC, for the GMC, described the gravity of the "thoughtless" and "easily avoidable" error as such that it amounted to a crime. The "abject, needless and inexcusable" negligence of each surgeon fell so far short of the standards expected of a reasonably careful surgeon, he insisted, it went far beyond "an episode of fault" that could be dealt with by civil liability or compensation.

The professional conduct committee heard that X-rays had been placed the wrong way round on an operating theatre viewing box and both doctors had ignored medical notes and failed to get consent for a right nephrectomy.

Mr Davies said both men's negligence "deserves to be, and in the public interest, should be, morally condemned as amounting to gross negligence - not just negligence but gross negligence."

Reeves, a retired pipe lagger, who had worked at Carmarthen Power Station, had the operation at the Prince Philip Hospital at Llanelli, in January 2000.

He died of respiratory failure in March that year after the error was spotted and he was transferred to the Morriston Hospital, Swansea, for specialist dialysis in a "desperate" attempt to make the remaining kidney work.

Mr Roberts and Mr Goel were prosecuted for manslaughter at Cardiff Crown Court in June 2002. But the prosecution's case collapsed after a key witness, the pathologist Dr Andrew Davison, told the court he could not be sure Reeves, of Burry Port, Carmarthenshire, died as a result of the blunder. The jury was directed to acquit. But Mr Davies stressed yesterday: "It is important for me to emphasise, and for you to appreciate, that the decision of the prosecution to offer no further evidence was based on the pathologist's evidence on his inability to prove to the criminal standard, that the respondents' negligence had caused Reeves to die. It was not brought about by a lack of evidence that each of them were grossly negligent - there was ample evidence each of them had been."

The barrister described the removal of the left organ - "the kidney that was keeping him alive" - as a "drastic surgical error".

"In fact, it was described by Roberts himself in the immediate aftermath when he produced his explanation the following day, as an error which was appalling," said Mr Davies.

The mistake came to light two hours after the procedure, when medical staff in the intensive therapy unit realised Reeves was not producing urine. When the surgeons read the patient and theatre notes the "catastrophic" error became apparent.

The doctors considered reimplanting the healthy kidney but this was not possible because it had been placed in sterilising fluid. Reeves was transferred to Swansea for dialysis in the hope that it would keep him alive. But it was a "desperate" attempt "doomed to failure".

Reeves continued to deteriorate and he contracted adult respiratory distress syndrome. The former pipe lagger, who retired aged 55, had already suffered from cardiovascular disease and a stroke before the abnormality in his right kidney was discovered in June 1999. The hearing continues.

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