A hospital has unreservedly apologised to the widow and family of a father of three who died from complications after surgery to remove cancer on his lung.
Following the apology in the High Court, the widow of 43-year-old Shane Banks, who died three days after a second operation to remove his lung at University Hospital Galway, said time will tell how much the apology means.
It comes as she and Mr Banks' extended family called for a new law to be introduced, making it mandatory for hospitals to disclose if a treating doctor is under supervision or being mentored.
Speaking outside the Four Courts, Mr Banks' wife, Ciara McDermott, said there has to be disclosure. “It means nothing if these things are not recognised,” she said.
She said the family had learnt things at the lecturer's inquest “that we had no idea what had been going on”.
“From the time Shane was admitted to the hospital he had not a hope,” she added.
Describing her husband's loss as horrendous, Ms McDermott said: “He was the love of my life. He was my husband. He was probably the best definition of a father I could have ever imagined. Ge loved our three children - they were only 2, 3 and 4-years-old when he died.”
She added that she has not been able to explain the exact circumstances of Mr Banks' death to their children yet.
“They think he went into the hospital with a pain, and he was sick, and they think he got so sick that the doctors did their very best to help him and couldn’t.
“I have to go down that route at the moment. I will have to go through years of going back through this and eventually let them look through the documents as to what really happened.”
Procedure
Mr Banks, a lecturer in business at Sligo Institute of Technology, died following the performance of a second operation for treatable lung cancer.
He underwent two operations: the second on June 21st, 2019, on the couple’s sixth wedding anniversary, but died on June 24th, 2019.
During the second surgery, major complications arose, the court heard. There was significant blood loss and Mr Banks had to be put on bypass. His condition deteriorated and he died three days later.
The apology was read in the High Court as Ms McDermott and his family settled actions against the HSE over his death. The terms of the settlements are confidential.
In the letter of apology, University Hospital Galway and the Saolta Group apologised to Ms McDermott and the extended family, acknowledging his “untimely death” and the “enormity of the personal loss to you of your beloved Shane”.
The letter from hospital general manager Chris Kane read: “I sincerely and unreservedly apologise for the failure to consider the introduction of proper supports for the thoracic surgery in Shane’s case and the deficits in the manner in which Shane’s surgery was carried out.”
It added: “If these had been in place and addressed, his death three days later would likely have been avoided. I acknowledge and regret the great upset, distress and loss suffered as a result.”
Mr Banks was admitted to the Galway hospital and a lobectomy was performed, which involved the removal of two lobes from his right lung. Following the surgery, Mr Banks was in ICU for three days and was treated for pneumonia.
However, the tumour was found to be “significantly invasive” and a second procedure was planned following discussion with a multidisciplinary team which took place on June 21st.
Death
The inquest heard that during the procedure, the right main pulmonary artery was torn and blood loss of 2.2 litres was recorded.
Two surgeons were called to assist and after the bleeding was stopped, Mr Banks' right lung was removed. He was brought to ICU after 1am and temporarily put on a ventilator.
In the early hours of June 24th, his condition was seen to deteriorate and he was given emergency treatment. However, he was later pronounced dead at 9.18am.
The cause of death was given as acute respiratory failure due to pulmonary oedema and damage in the remaining left lung, following removal of the right lung three days earlier.
An inquest, which ran for 15 days, returned a verdict of medical misadventure.
The coroner made a number of recommendations, including that a mentorship programme be established for doctors and that standard operating procedures for all cancer multidisciplinary teams be communicated to all hospitals, and arrangements for consultant leave be standardised to prevent situations arising where doctors go on leave soon after critical procedures.
The inquest heard the cardiothoracic surgeon involved in Mr Banks care was under mentorship and supervision for his cardiac practice at the time, but not for thoracic work and lung procedures.
'Distressing case'
In the High Court the family’s senior counsel Edward Walsh SC said it was a "particularly distressing case" involving the untimely death of a 43-year-old man due to a "catalogue of medical errors".
He said the surgeon involved had been the subject of a review carried out by the hospital in relation to his ability to undertake complex surgery.
Concerns had been raised in October 2017 re his clinical practice, and he had been appointed a mentor in surgical matters, but it was on an informal basis.
A further review the following year resulted in a more formal mentorship programme being put in place and subsequently extended by two months, during which time Mr Banks came under his care.
Mr Walsh said the second surgery was carried out on a Friday with only two junior doctors assisting.
It took twice as long as it should have and there was Counsel said a "catastrophic bleed" and "Shane almost bled out".
Counsel said the surgeon went on annual leave the next day and Mr Banks was in a state of decline over three days. That information counsel said was not made known to his wife and family.
Noting the settlements Mr Justice Paul Coffey said it was a very disturbing case.
Outside court the family solicitor Roger Murray said, fatally for Shane Banks, hospital management had failed to expand formal mentorship of the surgeon to cover the thoracic side of that surgeon’s practice.
Mr Bank’s surgery, Mr Murray said, was a high risk complex procedure and yet management allowed it to proceed late on a Friday with no senior surgical support or assistance.
Proper robust systems he said would have prevented Shane’s surgery proceeding in the manner it did, when it did and with the surgeon involved, he said.
“Put simply what happened to Shane must never happen again. The HSE must make meaningful the apology they offered and the coroner’s recommendation must be followed through in full. Candour and patient safety must become first, and it should not take a 15-day inquest for the full facts to emerge.
"Shane's family with great dignity have borne his tragic loss. They don’t want any other family to go through the suffering they have gone through. They are calling for the introduction of Shane’s law to make it mandatory for hospital to disclose if a treating doctor is under supervision or mentored. His memory deserves no less."
