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. 2004 Jan 31;328(7434):246. doi: 10.1136/bmj.328.7434.246-a

Doctors suspended for removing wrong kidney

Owen Dyer
PMCID: PMC1143788  PMID: 14751886

Two doctors who mistakenly removed a patient's only working kidney have been suspended for 12 months by the General Medical Council.

Mr John Gethin Roberts, a consultant urologist, and registrar Mr Mahesh Goel faced the GMC's professional conduct committee 18 months after being acquitted of manslaughter in the death of 70 year old patient Graham Reeves.

Mr Reeves underwent what should have been a right nephrectomy at the Prince Philip Hospital in Llanelli, South Wales, in January 2000. But under Mr Roberts's supervision, Mr Goel removed the patient's left kidney in error.

On discovering their mistake, the doctors carried out further surgery in an attempt to restore function to the chronically diseased right kidney but failed, and Mr Reeves was placed on dialysis. He developed septicaemia and died in March 2000, five weeks after the first operation.

Both doctors were tried for manslaughter at Cardiff Crown Court in June 2002. The prosecution's case collapsed, however, after a pathologist told the court he could not be sure Mr Reeves's death was a direct result of the mistake.

Mr Roberts attended the GMC hearings and admitted most of the charges. He has been suspended on full pay by Camarthenshire NHS Trust since 2000. Mr Goel was unrepresented and is believed to be in India. He told the GMC he could not attend the hearing for pressing family reasons. His contract with the trust was not renewed when it expired in August 2001. He then brought proceedings in the Cardiff Employment Tribunal for unfair dismissal and racial discrimination but lost his case.

The professional conduct committee heard that Mr Goel, returning from a 10 day study leave a month before the operation, made an incorrect entry into the Urology Department diary, using the information on a wrongly completed admission slip. He conducted a ward round on the morning of the operation but did not speak to Mr Reeves as he was asleep.

The error was compounded in the operating theatre when Mr Roberts placed the x ray back to front and positioned Mr Reeves for a left nephrectomy. Mr Roberts told the hearing: "I followed my usual practice—except for not going through it with my registrar—and became convinced the left side was the correct side. My credibility with myself has been very severely dented."

GMC committee chair Dr Chitra Bharucha said such errors were understandable, but the doctors had committed serious professional misconduct by failing to consult each other or the x ray adequately. She added that they could have avoided their mistake by comparing the surgery list with Mr Reeves's medical notes or his consent form. In view of their previously unblemished records, she said, striking off would be disproportionate.

The trust said lessons learnt in the case are now applied throughout the NHS in Wales.


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