Police probe after unexpected death of patient at Welsh hospital

A police investigation was launched and doctors interviewed after the unexpected death of a patient following surgery at Wales' largest hospital. The risk of cancer patient Donald Gough dying during liver surgery had been assessed by surgeons at the University Hospital of Wales as 5% at most, an inquest at Pontypridd Coroner's Court heard. Consultant anaesthetist Dr Benjamin Holst broke down at times when he told the hearing on June 2 that he had led the team on anaesthesia for 77-year-old Mr Gough's surgery. For the biggest stories in Wales first sign up to our daily newsletter here He told the hearing that it appeared Mr Gough had died from low blood sugar after the administration of insulin during the procedure but they don't know how this happened. Mr Holst and other doctors, including the surgeon leading the operation, also denied giving the patient insulin and said there would have been no reason to do so. Asked by coroner David Regan about the cause of death, Dr Holst said it was "overwhelmingly likely cause of death was low blood sugar by administration of insulin, we know not how." Bowel cancer patient Mr Gough died in the hospital's ICU on November 5, 2022, after the operation to remove secondary tumours in his liver. He had also suffered a chest infection on ICU, the hearing was told. Breaking down in tears Dr Holst said he had not given Mr Gough the care he should have when the operation had ended. Asked by counsel for the family Bramble Badenoch-Nicolson, asked about the lack of help - he would usually have had an assistant anaesthetist - and Dr Holst replied: "In terms of my care, or lack thereof, once Mr Gough got to recovery, I am sure the fact I was exhausted had a bearing on it." He had already told the hearing he felt he should have handed over recovery care better. Clearly emotional on the second day of the inquest, Dr Holst admitted he had left Mr Gough, before he should have done, when the patient was taken to recovery after surgery. He told the coroner David Regan he was now on sick leave. "I dropped Mr Gough in recovery and went home. I should not have ceased responsibility that early and that was a deficiency in my care," he told the hearing, adding, "I have not been enjoying the best of mental health." He added: "Until he had woken I would have retained some responsibility unless I had made arrangements for other care to be taken over and the other doctor had exlicitly acknowledged that. "That's not the correct handover for patients. I ought to have done that after we got to recovery, not before. There should have been a second meeting." Asked by the coroner if he wanted to take a break, Dr Holst said he would prefer to continue giving evidence. He had worked closely with consultant surgeon Giorgio Alessandri leading the operation and was present throughout the hours' long procedure, as was usual. Asked whether he, or anyone else, had administered insulin to Mr Gough during the operation Dr Holst said he had not, although he agreed there were stocks of insulin in the anaesthetist's fridge, which was unlocked. This was usual practice as insulin is not a controlled drug, but the fridge was in the controlled entry operating theatre area. Along with other medics present Dr Holst said he only had sight of the surgery site of Mr Gough and that the rest of the patient's body was draped, as was usual, during operations. "Every inch of Mr Gough other than the operation site was covered in drapes. No one could approach without anyone noticing, if that's what you are asking," Dr Holst told the coroner, adding, "It does not seem plausible to me that some one had access illicitly." He added that it was "improbable" anyone could access any vials in the operating theatre "and put things in them". Mr Gough was given a pain killing epidural for the keyhole surgery which included a "small amount of fentanyl". But it was unlikely the fentanyl, an opiod, caused Mr Gough not to wake up after the surgery, said Dr Holst. "Mr Gough failed to wake up after, but if that was due to fentanyl overdose his respiratory rate would have been lower than it was. I don't think it was ever likely to have been the fentanyl." Asked by the coroner whether he had any idea how insulin may have come to be in Mr Gough's body he relied: "It's very hard to see how it could have been administered in error accidentally and anything else is just implausible." At this point the coroner again reminded the consultant anaesthetist he did not have legal representation and there was a break in proceedings. Earlier in the hearing a junior surgeon, also involved in the surgery, admitted he took photographs of Mr Gough's liver sample on his personal phone. Apologising to Mr Gough's family, who were at the hearing, Dr Gerard McKnight denied the images were taken for fear that something had gone wrong during the procedure. Dr McKnight, who the hearing was told had been interviewed by police, along with other doctors involved in Mr Gough's surgery, said that he took the photos on his personal phone for training and education purposes. He had not taken the decision to take pictures alone, he had done so after discussion with the consultant surgeon leading the operation, Giorgio Alessandri. During several hours of questioning by the coroner and counsel for the family and hospital, Dr McKnight, who now works for Aneurin Bevan Health Board, admitted there was no documented discussion of the images being taken or the reasons, as there should have been. Addressing Mr Gough's grieving family who were in court Dr McKnight expressed his condolences and assured the family that only himself, Dr Alessandri and "the legal team" ever saw the images of his liver sample. As a year four junior surgical registrar at the time Dr McKnight estimated he had experienced around 700 operations during his time at UHW. He said a more junior doctor, Eliott Carrington-Windo, had stitched up the patient after Mr Alessandri finished the operation and left the theatre to write up notes. Giving evidence on the first day of the hearing on June 1 Mr Alessandri had told the inquest he had returned to check Mr Gough in recovery three times, expecting him to be doing well, but Mr Gough was not awake. Questioned separately, each for several hours, on their roles in the procedure, Mr Alessandri, Dr McKnight and Dr Carrington-Windo admitted they did not have very good memories as it had been years ago, but that they recalled the operation had seemingly gone well with no concerns. Asked about the need to provide local anaesthetic pain relief at the end of the procedure they told the hearing that correct protocols had been followed. Vials of the anaestehtic to be injected, the amount and expiry date of the medication had been checked and labels read out. All three also denied any knowledge of insulin being administered and said they could see no reason for this to have been done. Mr McKnight said insulin has a pronounced "acrid" smell which surgeons would be familiar with. The hearing continues. Get daily breaking news updates on your phone by joining our WhatsApp community here . We occasionally treat members to special offers, promotions and ads from us and our partners. 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