Mystery over man's sudden death at Cardiff hospital

Police have issued a statement into the investigation of an unexpected death of a patient at Wales' largest hospital. The statement on June 3 came as operating theatre staff at the University Hospital of Wales in Cardiff insisted drug administration protocols were followed during cancer patient Donald Gough's operation. They told the third day of an inquest into his death that they saw no one unauthorised approach or inject Mr Gough, who died unexpectedly after surgery. Giving evidence at Pontypridd Coroners' Court, theatre staff present at his operation also outlined security procedures at the 15-theatre complex at UHW. A police investigation was launched and doctors questioned when Mr Gough, 77, deteriorated unexpectedly at the hospital. In an update on Wednesday, June 3, separate to the inquest, South Wales Police said: "On the evening of Tuesday October 11, 2022, Cardiff and Vale University Health Board contacted South Wales Police to report concerns for a patient who had deteriorated after surgery. "On November 5, 2022, South Wales Police was notified by the Cardiff and Vale University Health Board that the patient, Donald Gough, 77, had died at the University Hospital of Wales, Cardiff, after experiencing unexplained high levels of insulin in his system. "South Wales Police commenced a joint investigation with the health board to understand how Mr Gough had become unwell and what had led to his death. "We consulted with the Crown Prosecution Service throughout the investigation and subsequently prepared a file of evidence on behalf of HM Coroner. There is currently no ongoing criminal investigation." For the biggest stories in Wales first sign up to our daily newsletter here Insulin should not have been administered to bowel cancer patient Mr Gough when he underwent the eight-hour procedure to remove secondary tumours in his liver, which also involved removing his gall bladder, the inquest was told. On the third day of the hearing coroner David Regan questioned theatre staff having already heard from the lead surgeon, doctors and the consultant anaesthetist in charge of the surgery. All said they had thought the procedure had gone well. Mr Gough's risk of mortality had been assessed as five per cent at most. Asked whether he saw anyone trying to inject Mr Gough without authoritisation, the anaesthetic practitioner for the surgery, Alexander Gwatkin, told the coroner he had not. Mr Gwatkin added that he had not seen anything untoward or anyone approach the patient unexpectedly during the procedure. He and other staff said they did not believe they or anyone else present had muddled up any drugs administered to the patient. A sample of insulin was produced in evidence for the court to examine. Legal teams and the coroner looked at the insulin and other medicine vials and how they differed. They were also asked to smell the insulin after being told the drug has a particular aroma which medics would be familiar with. Earlier in the week the consultant anaesthetist controlling what drugs the patient received during surgery broke down as he said he hadn't given Mr Gough the care he should have. Dr Benjamin Holst, and doctors carrying out the operation, denied giving Mr Gough insulin and said there would have been no reason to. Dr Holst said it appeared the patient had died as a result of insulin in his body, but it was unclear how it had got into his system. UHW operating theatre practitioners helping with Mr Gough's surgery denied medicines given may have been muddled up. They detailed how medication is crossed checked before being given and said only the consultant anaethsetist decides what drugs can be administered. Questioned about security at UHW's operating theatre complex and his role during Mr Gough's surgery anaesthetic practitioner, Mr Gwatkin said he did not administer medicines himself but had keys to the drugs cupboard. He removed items only at the request of the anaesthetist and everything was cross checked and noted, he said. Controlled drug stocks were checked twice a day to check what went in and out. Entry into the theatre complex was by swipe card only but there were no searches to check people were not taking drugs out and no records of who swiped in and out. Insulin, which must to be kept cold and is not a controlled drug, is stored in a fridge. Asked by coroner David Regan whether he was ever aware of insulin going missing, Mr Gwatkin said he wasn't aware. During Mr Gough's surgery Mr Gwatkin said his role was to set up equipment to help if there was excessive bleeding, as could occur during liver surgery. He said he was "outside the sterile field" and would never have approached the patient unless there was a life-threatening emergency and never administerd drugs himself. He agreed that Dr Holst had not had an assistant anaesthetist, as he should have done that day, and could not therefore take breaks. Asked by the coroner whether he saw anything "unexpected or untoward" during the operation, Mr Gwatkin said he didn't. Asked what he would have done if someone not authorised had approached the patient, he replied: "Stopped them." Scrub practitioner Delfin Balbeara, whose role included preparing and checking trays of equipment for Mr Gough's operation, said he was seated at the foot of the patient, was present throughout the surgery, apart from breaks, and also saw nothing untoward. Mr Balbeara recalled drawing up local anaesthetic, as requested, before giving it to the surgeon. He described following the protocol of showing the doctor the ampule and checking it was the correct date and strength. He and Donna Seoquena, senior theatre practitioner, and scrub practioner Georgia Platten, also gave evidence - adding they would have stopped anyone or noticed anything unexpected. Asked if drug ampules could be confused by staff, Ms Seoquena said she thought this was highly unlikely, owing to strict procedures to read labels and make multiple checks. Ampules were also different, with some in glass and some in plastic bottles, the inquest was told. While local anaesthetic used would have been in a one-use ampule, insulin was in a multiple use bottle with a signature grey plug bung. The hearing continues. Get daily breaking news updates on your phone by joining our WhatsApp community here . 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