The investigation into the death of Luke Glendenning last November raised eight “service delivery problems” and resulted in 10 recommendations, and the procedure is still suspended by Leeds Teaching Hospitals.
The Trust, which has given the family a cash settlement for clinical negligence, has not admitted culpability in Luke’s death, despite the raft of concerns, including whether the surgeon who performed the surgery - who had recently taken over the paediatric urology service and had only had “a small number” of cases in the UK, was properly mentored.
Other concerns investigated included whether invasive life support techniques, used in the days after Luke was first operated on, were warranted, and a lack of a “multidisciplinary approach” that meant a professor from Sheffield Children’s Hospital, who had been acting as a mentor to the surgeon, was not consulted before the decision was made to go ahead with the operation, nor was a radiologist who was involved with Luke’s initial care.
Neither attended a “theatre team brief” held before the surgery.
Luke was a “fit and healthy” 10-year-old when he was first taken to hospital in June, after falling from a climbing frame, however, a CT scan revealed a large stone in his left kidney. Later, multiple stones were discovered.
He was admitted for surgery on November 6, but after “more and more things went wrong” and six operations in the space of 72 hours, his parents, from Swarcliffe, had to make the painful decision to switch off life support on November 9.
Leeds Teaching Hospitals launched an investigation into his death, and while the report does not identify a “single root cause” for his deterioration, it says that due to the effects of the treatment given to Luke when his body filled with fluid after the first operation, combined with bleeding complications “resulted in his condition being unrecoverable within the first 24 hours”.
His mother Sue Hirst, 35 and father Richard Glendenning, 39, have met with the investigator who prepared the report, but say questions remain as to why so many things went wrong.
Miss Hirst said: “I still don’t understand why doing nothing was not a viable option when Luke had no symptoms? He wasn’t suffering so why not just leave and monitor him?
“Not all the complications were mentioned to us and we were not informed of the likelihood of such complications.”
Miss Hirst said the family were never told that it may require multiple operations to remove Luke’s kidney stones - something that would have impacted their decision to go ahead, she says.
“We were ‘sold’ the procedure as it was the least invasive with the quicker recovery time - not necessarily the case if Luke would have needed to undergo two or three procedures,” she said. “The Trust has work to do around the consent process.”
The report also reveals the supervising professor, who attended Luke’s original operation, left half-way through the procedure.
Miss Hirst said: “We assumed the Professor was attending as he had taken an interest in Luke’s case and the fact that Luke had so many large kidney stones but no symptoms. We were not aware he was meant to be overseeing the procedure. Knowing this may have had some bearing on our decision. The fact that he didn’t fully understand his role and that he left half way through the operation just astounds me.”
Luke’s parents, under the advice of a solicitor, accepted a settlement of £23,000 from Leeds Teaching Hospitals.
Miss Hirst said: “It was never about the money for us, it was about them admitting they caused Luke’s death. We have had apologises from the trust, in the sense that they are sorry Luke had died, but they have never said sorry for causing his death. It’s difficult to accept what has happened. Luke was a happy and healthy 10 year old boy. I’m hoping the inquest will provide us with some answers and help to provide closure for our family.”
Dr Yvette Oade, Chief Medical Officer at Leeds Teaching Hospitals NHS Trust said: “I would like to offer my heartfelt condolences to Luke’s family and to reiterate our sincere apologies. We have discussed the findings of the report with Luke’s family and would like to offer a further opportunity to address any outstanding concerns that they may have. We are continuing to work hard to implement the recommendations from the report and to ensure that lessons have been learned.”