Department of Health
Central Government
Noted
The Department of Health acknowledges the concerns, notes BAUS's definition of nephroureterectomy, and states that decisions on clinical team operations are for the local Trust to address, also suggesting the GMC as the appropriate body for fitness to practice concerns. (AI summary)
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Dear Mr McLoughlin,
Thank you for your letter following the inquest into the death of Pauline Taylor. I was very sorry to hear of Ms Taylor’s death and wish to extend my sincere condolences to her family.
In 2010 Ms Taylor underwent a nephroureterectomy procedure to remove her kidney and ureter. The surgeon who had decided on this operation envisaged that this procedure would remove the kidney and the entirety of her ureter as far as the bladder wall. However, a different surgeon performed the operation and removed approximately 5cm of the ureter, leaving the remainder in situ.
The second surgeon believed the term nephroureterectomy allowed discretion as to the proportion of the ureter to be removed.
This difference in understanding of the term between the two surgeons was not uncovered until some months later, by which time Ms Taylor had a tumour in the junction between her distal ureter and her bladder which was considered to be inoperable. Following this, metastases were also identified in her liver and lungs. The inquest concluded that Ms Taylor died from metastatic carcinoma.
You raise the following concerns:
The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid misunderstandings between clinicians as to the extent of the procedure to be performed. Two surgeons who gave evidence at the inquest differed in their understanding of the term – one considered the term involved the removal of a kidney and the entire ureter whilst the other surgeon considered the term allowed for the removal of only a portion of the ureter.
In this case no firm diagnosis had been established and there was no one person in the clinical team whose role was to monitor progress and liaise with the patient and the other clinicians. Evidence was heard at the inquest about the benefits of a “case manager” role, used in other NHS Trusts in complex and uncertain cases.
I note that you sent a copy of your report to the British Association of Urological Surgeons (BAUS), for their interest.
My officials have liaised with BAUS as the most appropriate organisation to advise concerning definition of the term “nephroureterectomy”. In the opinion of BAUS, the term nephroureterectomy means the removal of the kidney together with the whole ureter. BAUS have advised that there may be circumstances where it is not possible to remove the whole ureter. Where this is the case the finding should be clearly recorded in the notes and appropriate arrangements made for follow-up with the patient.
Decisions on how each clinical team operates and the specific roles within teams are issues for the employing Trust. Decisions need to be taken based on the relative skill mix and experience of the clinicians involved, as well as the complexity and seriousness of the cases handled. Your concern about the lack of a clinical “case manager” in this particular case is a matter for the local Trust to address.
Lastly, it is not clear from this case if any complaint has been made to the General Medical Council (GMC). Concern about a doctor’s fitness to practise should be raised with the GMC, as the appropriate regulatory body independent of government.
I hope that this response is helpful and I am grateful to you for bringing the circumstances of Ms Taylor’s death to my attention.
Best wishes,
DR DAN POULTER
Thank you for your letter following the inquest into the death of Pauline Taylor. I was very sorry to hear of Ms Taylor’s death and wish to extend my sincere condolences to her family.
In 2010 Ms Taylor underwent a nephroureterectomy procedure to remove her kidney and ureter. The surgeon who had decided on this operation envisaged that this procedure would remove the kidney and the entirety of her ureter as far as the bladder wall. However, a different surgeon performed the operation and removed approximately 5cm of the ureter, leaving the remainder in situ.
The second surgeon believed the term nephroureterectomy allowed discretion as to the proportion of the ureter to be removed.
This difference in understanding of the term between the two surgeons was not uncovered until some months later, by which time Ms Taylor had a tumour in the junction between her distal ureter and her bladder which was considered to be inoperable. Following this, metastases were also identified in her liver and lungs. The inquest concluded that Ms Taylor died from metastatic carcinoma.
You raise the following concerns:
The surgical term ‘nephroureterectomy’ appears to lack sufficient precision to avoid misunderstandings between clinicians as to the extent of the procedure to be performed. Two surgeons who gave evidence at the inquest differed in their understanding of the term – one considered the term involved the removal of a kidney and the entire ureter whilst the other surgeon considered the term allowed for the removal of only a portion of the ureter.
In this case no firm diagnosis had been established and there was no one person in the clinical team whose role was to monitor progress and liaise with the patient and the other clinicians. Evidence was heard at the inquest about the benefits of a “case manager” role, used in other NHS Trusts in complex and uncertain cases.
I note that you sent a copy of your report to the British Association of Urological Surgeons (BAUS), for their interest.
My officials have liaised with BAUS as the most appropriate organisation to advise concerning definition of the term “nephroureterectomy”. In the opinion of BAUS, the term nephroureterectomy means the removal of the kidney together with the whole ureter. BAUS have advised that there may be circumstances where it is not possible to remove the whole ureter. Where this is the case the finding should be clearly recorded in the notes and appropriate arrangements made for follow-up with the patient.
Decisions on how each clinical team operates and the specific roles within teams are issues for the employing Trust. Decisions need to be taken based on the relative skill mix and experience of the clinicians involved, as well as the complexity and seriousness of the cases handled. Your concern about the lack of a clinical “case manager” in this particular case is a matter for the local Trust to address.
Lastly, it is not clear from this case if any complaint has been made to the General Medical Council (GMC). Concern about a doctor’s fitness to practise should be raised with the GMC, as the appropriate regulatory body independent of government.
I hope that this response is helpful and I am grateful to you for bringing the circumstances of Ms Taylor’s death to my attention.
Best wishes,
DR DAN POULTER