'Lessons taken' from nurse death

Janine Murtagh died after a routine operation

The Royal Victoria Hospital has apologised for the death of one of its patients in 2002.

Janine Murtagh, 31, from Crumlin, who was also a nurse at the hospital, died following a delay in an operation.

An independent review published on Wednesday found there was confusion about access to emergency theatres.

The review's authors said nurses and doctors were not sufficiently sensitive to a patient whose condition didn't improve as would be expected.

The Regulation and Quality Improvement Authority's report - commissioned by former health minister Angela Smith a year ago - was critical of team working at the Royal in Belfast and made a total of 11 recommendations.

These include the need for better training of staff and clearer guidelines about what to do when things go wrong.

Stella Burnside, who carried out the review, said lessons had to be learned from Mrs Murtagh's death.

"It think it is very important that we understand how the family feel," she said.

"But when the independent experts reviewed the case, and the case had been reviewed and investigated by the coroner's court they did not believe that it was individual action culpability that was responsible."

"That seems to be the case in what we have investigated. "

Areas of concern include:

• consent
• patient care
• leadership and communication
• the implementation of policies and procedures.

However, Mrs Murtagh's husband, Stephen, said the report did not go far enough.

"This report is a case of the health service investigating itself," he said.

We are remembering her in every action we take to improve patient safety William McKee RVH

"Our major concerns have not been answered.

"It cannot bring any closure whatsoever. It further distresses ourselves and makes a difficult situation even more difficult."

In October 2002, Mrs Murtagh, who worked as an auxiliary nurse, went into the Royal in Belfast for a routine abdominal operation.

But during the surgery her small bowel was ruptured and no-one noticed. The next day at around 2100 GMT doctors decided she should have an emergency operation.

However, it took until 0100 GMT the following morning to get an emergency theatre - and staff - organised.

At Mrs Murtagh's inquest, the coroner said this delay had played a part in her death.

Speaking on behalf of Royal Hospitals, chief executive William McKee unreservedly apologised to the family and said the hospital was working hard to learn lessons from what had happened.

"We cannot bring her back, but we are remembering her in every action we take to improve patient safety," he said.

"Since Janine died in 2002, we have put a wide range of measures in place to minimise the risk of anything similar happening in the future."

Health minister Shaun Woodward said: "Undoubtedly, the hospital must learn lessons, but these must also be applied across the health service in Northern Ireland."