Coroner rules 'no medical negligence' involved in fatal brain surgery in Sheffield

Tracy Gambrill tragically died on November 19, 2016 - 12 days after undergoing brain surgery at the Royal Hallamshire Hospital in Sheffeld to treat her drug-resistant epilepsy.

An inquest into her death found that her head had likely moved during the surgery, causing a total of three incisions to be made at the wrong trajectory and at “excessive” depths. This ultimately caused a serious brain injury, and death.

Close to seven years after her death, assistant coroner Susan Evans concluded at the end of the five-day inquest, on October 20, that medical negligence was not a contributing factor in Tracy’s death.

Over the week, it was heard in court that Tracy, who was a civil servant, was diagnosed with epilepsy at the age of 10. It was drug-resistant, which made her seizures “difficult to control”. She was also suffering from non-epileptic attacks.

Tracy was referred to neurology at Sheffield Teaching Hospitals NHS Foundation Trust, where it was decided Mr Dev Bhattacharyya, a Sheffield consultant neurosurgeon, would perform a surgery known as SAH. This would see the part of the brain removed that was responsible for causing the seizures.

The court heard that Mr Bhattacharyya was an experienced neurosurgeon who had performed around 80 of these operations at that time. The surgery took place on November 7, 2016. Mr Bhattacharyya was assisted by a relatively junior surgical registrar who had described himself as “book knowledge aware” regarding the surgery.

In his evidence, Mr Bhattacharyya said the position of Tracy’s head - stabilised by clamps - was “extremely important” for the surgery, and it was his responsibility to ensure this.

Neither Mr Bhattacharyya nor the surgical registrar recollected any issues, but it was noted that Tracy was draped, and it was difficult to tell her

position.

Mr Bhattacharyya said there are no ‘anatomical landmarks’ inside the brain. Incisions are based on 'trajectory' which can be helped with the use of ‘BrainLab’ - a piece of equipment that uses scans of the brain to assist in surgery.

It was heard that Mr Bhattacharyya had difficulty finding the temporal lobe inside the brain, but he was “confident” he was cutting laterally rather than medially, which is “where there are all the dangers” if cut into.

A total of three incisions were made to locate the temporal lobe which coroner Evans said were “all at different trajectories and far too long”. There was varying evidence from experts given on the length of the incisions, but it was heard that Mr Bhattacharyya cut at least 2.5 times too deep.

'An awful mistake'

After the first incision, Mr Bhattacharyya had said he was “lost” and had made an “awful mistake” - but he did not stop the surgery. After the third incision, which was done with BrainLab, he said he had felt unwell and he called for assistance from another surgeon, who successfully located the temporal lobe.

Mr Bhattacharyya finished the rest of the surgery, but tragically when medical professionals tried to wake Tracy up from the anaesthesia it was “immediately apparent” she had sustained a serious brain injury.

Coroner Evans said it was likely Tracy’s head had moved prior to the first incision being made, but “it does not however provide a reason why the incision was so deep… There was clearly a serious error in relation to the depth of the incision”.

However, she said the “mistake” did not constitute medical or criminal negligence.

Mr Bhattacharyya has not performed this surgery since.

Giving a narrative conclusion, Coroner Evans said Tracy would have likely died as a result of brain damage caused by the first incision.

An investigation is ongoing by the General Medical Council.

'Several avoidable errors'

Following the inquest, Lee Gambrill, Tracy’s brother, said: "We are very disappointed that, after almost seven years of seeking answers as to why this happened, we are now told it was simply an accident.

"However, it’s an accident that could easily have been avoided and our aim now is to ensure measures are put in place so that this doesn’t happen to anyone else. We therefore welcome the continued investigation by the General Medical Council."

Stephanie Prior, a medical negligence partner from Osbornes Law, who represented the family, said: "It’s clear there were several avoidable errors in this tragic case and it’s therefore appropriate that the General Medical Council should continue their investigation to ensure greater safeguarding in the future.

"Despite the heartbreak, distress and anguish caused by this seven-year battle for answers, the family have continued to act in a dignified manner and have been extremely patient in their wait for this inquest to be held."

Dr Jennifer Hill, Medical Director, Sheffield Teaching Hospitals NHS Foundation Trust: “During Ms Gambrill’s brain surgery in 2016 there was a serious error and tragically she passed away shortly afterwards. We have apologised unreservedly for what happened, but I realise that no apology will ever be enough to alleviate the loss Ms Gambrill’s family and friends feel.

"We have conducted a thorough investigation which led to wider learning and this learning process will continue following the inquest and its findings. We have shared this information with Tracy’s family and hope it provides some reassurance about how seriously we have taken her death.”