Case 1: A 47-year-old woman was admitted to a neurosurgical unit in a District General Hospital suffering from a benign tumour of spinal nerve sheaths and an infection. Surgery was delayed because there was no high- dependency unit bed, no immediate access to a theatre, no neurosurgical nurses, and lack of monitoring equipment. Surgery took place two weeks after a decision to operate was made, and she died of meningitis 14 days later.
NCEPOD conclusion: Hospitals with this level of resource should not be undertaking this type of surgery.
Case 2: A 26-year-old man was admitted to a specialist unit in a District General Hospital for removal of a blood clot on the brain. He was seen by a registrar surgeon and by the senior house officer anaesthetist, both of whom had two years' experience. The operation took place at 4am on a Saturday. He died the same day.
NCEPOD conclusion: The team was "grossly inadequate" for the task.
Case 3: A 26-year-old man injured in a major road accident was admitted to a hospital with no intensive care unit. He waited 18 hours for surgery and died from kidney failure shortly after being transferred to another hospital.
NCEPOD conclusion: The patient should never have been admitted to the hospital in the first place.Reuse content