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Woman Dies In Organ Removal Mix-Up

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Woman Dies In Organ Removal Mix-Up

An elderly woman has died after a surgeon tried to remove her liver instead of her kidney…

An elderly British woman has died after an experienced surgeon attempted to remove the wrong organ during surgery.

Amy Joyce Francis, 77, was scheduled to have her kidney removed at the Royal Gwent Hospital in Wales, instead the doctor tried to remove her liver. The complications lead to a huge loss of blood and as a result, Mrs. Francis suffered a fatal heart attack.

At the inquest, consultant urologist Adam Carter, the surgeon who performed the operation, explained that Mrs. Francis underwent keyhole surgery to remove a cancerous right kidney. After making the incisions, Mr. Carter asked a trainee doctor to remove the organ because that is easiest part of the procedure.

However, inside the body the trainee found the peritoneal sac the organ the thin membrane protecting the liver –covered by more fluid and matter than normal. Not confident enough to proceed Mr. Carter took over.

At this point of the surgery the endoscopic camera cannot be used, and the doctors must work by touch alone.

Mr. Carter mistakenly grabbed hold of Mrs. Francis’s liver and pulled down on it causing it to rupture. The anesthetist immediately reported a fall in the patient’s blood pressure. Carter said he knew at that point he had torn the wrong organ. Two senior surgeons were called to the scene but were unable to save her.
Mr. Carter said it was possible that the trainee had breached the peritoneal sac while she was trying to reach the organ:

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. [BBC]

The courts declared the verdict an unintentional mistake. The coroner for Gwent released this narrative:

Whilst undergoing keyhole surgery for the necessary removal of the cancerous right kidney, Mrs. Franciss liver was ruptured when it was mistakenly and unintentionally identified as the kidney and was catastrophically torn and damaged, resulting in death. [BBC]

The family, saddened by their loss but grateful for the doctors efforts accepted the verdict. 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 mothers life…

We appreciated Mr. Carters 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. [BBC]

As a result of the tragic death, the procedure has been modified to prevent any similar mistakes, and these adjustments have been communicated to the medical community worldwide.

Since the death, Mr. Carter has carried out the operation 20 times without complications.


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