Amy Francis inquest: Patient died after organ operation mix up Published duration 12 January 2012

A woman died after an experienced surgeon unintentionally attempted to take out the wrong organ during an operating theatre complication.

Amy Joyce Francis, 77, was due to have a kidney removed at the Royal Gwent Hospital in July 2010 but instead the surgeon tried to remove her liver.

The woman from Newport suffered a fatal heart attack after a loss of blood.

The coroner recorded a narrative verdict which was fully accepted by the Aneurin Bevan Health Board.

The inquest was told how Mrs Francis, a retired accountant, underwent keyhole surgery to remove a cancerous right kidney.

Consultant urologist Adam Carter told the hearing that Mrs Francis was to undergo keyhole surgery in order to avoid large surgical wounds and ensure a shorter recovery time so that her left kidney could be treated quicker.

Mr Carter said the removal was the easiest part and he asked a trainee present, who had never done it before, to carry it out.

The beginning of the routine operation went as expected with a 2-3 inch incision made in the groin area.

But, the court was told, when it came to removing the kidney, the peritoneal sac was covered by more fluid and matter than usual.

A trainee surgeon was in the theatre that day, and that registrar put her hand in to remove the kidney, but the registrar became unsure, lost her confidence and Mr Carter took over.

He said it was possible that while she was manipulating the organ the thin membrane protecting the liver, the peritoneal sac, was breached.

The inquest then heard how the surgeon felt what he believed was Mrs Francis's kidney and pulled down sharply, a normal procedure for organ removal.

But, the coroner was told, the anaesthetist immediately reported a fall in the patient's blood pressure. Mr Carter said he immediately realised he had pulled on the liver and, as a result, had torn the organ.

Two senior surgeons were called to the scene and efforts were made to save Mrs Francis, but they were unsuccessful.

"I think that what happened is that the peritoneum had been breached and the liver fell down and became more accessible than it usually is," Mr Carter said.

He added that the kidney may well have been pulled down out of place as well.

"I put my hand inside and felt an organ and I pulled it," he added.

Mr Carter said as a result of the death, operating procedure had been modified slightly and the new method communicated "worldwide".

Internal investigation

He said he had carried out the procedure 20 times since the death without a problem.

David Bowen, the coroner for Gwent, recorded a narrative verdict after formally summarising the facts of the case.

"Whilst undergoing keyhole surgery for the necessary removal of the cancerous right kidney, Mrs Francis's liver was ruptured when it was mistakenly and unintentionally identified as the kidney and was catastrophically torn and damaged, resulting in death," he said.

Mrs Francis' son, Alan, said: "We accept the decision and we also accept that Mr Carter and his team acted in good faith to prolong my mother's life."

Speaking outside the court, he added: "We appreciated Mr Carter's honesty and him coming along here today and hope that we can put it all behind us now.

"I think that it was the honesty that saved the hospital. If we thought that they had not answered our questions it would have been different. This was an honest mistake."

After the inquest, a statement from Aneurin Bevan Health Board said it fully accepted the narrative verdict, and its thoughts were with the family and friends of Mrs Francis.

It added: "A full internal investigation was undertaken which examined in every detail every action taken prior to and during the operation.