Surgeon found guilty of professional misconduct over death of Limerick teenager
Jessica Sheedy, 19, suffered multiple organ failure and died three days after complications arose during surgery for the removal of a tumour in her abdomen.
A surgeon has been found guilty of professional misconduct and poor professional performance by the Medical Council over delays in seeking help for a teenager who died after suffering massive blood loss during surgery.
University of Limerick’s Dr Ashish Lal admitted to the fitness-to-practise committee he did not ask for help during the complex surgery, which he admitted performing without having adequate experience or surgical support.
On Tuesday, during a short hearing at the inquiry, the committee found Dr Lal guilty on three counts of professional misconduct and 10 counts of poor professional performance in relation to the death of 18-year-old Jessica Sheedy.
During the hearing, which began on Monday, the committee heard Dr Lal — who was present for the inquiry — did not seek assistance from a vascular surgeon “in a sufficiently timely manner” after Ms Sheedy suffered major blood loss during the procedure he performed on her on May 8, 2018.
The beauty therapist from Bruff, Co Limerick, suffered multiple organ failure and died three days later following complications that arose during surgery for the removal of a tumour in her abdomen.
Dr Lal made full admissions to three allegations of professional misconduct and 10 allegations of poor professional performance between November 2017 and May 2018.
Members of Ms Sheedy's family were present at the two-day hearing.
On Tuesday, the fitness-to-practise committee said there were “serious failings” in relation to Dr Lal's performance that fell below the standards expected of doctors.
The inquiry found Dr Lal presented the case before an oncology multidisciplinary team meeting on January 19, 2018, in circumstances where he knew or ought to have known this was not the appropriate forum to discuss the treatment plan and/or consideration of surgery in relation to the patient.Â
Under commencement of the intra-operative hemorrhage, he:
- Failed to take appropriate steps by stopping/pausing the procedure and failing to await vascular surgical assistance;
- Did not seek vascular surgical assistance in a sufficiently timely manner;
- Misleadingly stated and /or documented to his colleagues and/or the patient’s family that he had obtained a second opinion on proceeding with a biopsy.Â
An expert witness for the Medical Council, Anant Desai, claimed it was “a deliberate act” by Dr Lal so his decision to carry out the surgery would not be challenged, which had “profound consequences".
The committee said all factual allegations against Dr Lal — which he admitted — had been proven beyond all reasonable doubt.
The inquiry heard a rare but benign form of tumour measuring 14cm had been detected in Ms Sheedy's abdomen after she had presented at UHL in October 2017.
The committee heard Dr Lal had underestimated the complexity of the surgery and had failed to plan adequately for the potential risks and adverse outcomes associated with the procedure.
The Medical Council’s barrister Neasa Bird said Dr Lal also failed to review CT images of the tumour with a radiologist before the operation.
Ms Bird said Ms Sheedy had to be brought back to theatre for further emergency surgery due to an inadequate blood flow to her legs, and she also had to have her entire large intestine removed.
After her death three days later, Ms Sheedy’s parents, James and Ann Sheedy, made a formal complaint to the Medical Council.Â
University Hospital Limerick has since apologised to the Sheedy family.
In a statement, HSE Mid West said Ms Sheedy lost her life because of a “series of significant and avoidable clinical errors in the lead-up to and during her surgery”.
It said its investigations concluded that adequate safeguards were not in place to prevent this high-risk operation.
“There is no doubt that we failed Jessica and her family. The failure was one of significant proportions, with clear catastrophic consequences. It is with a profound sense of remorse and regret that Jessica lost her life owing to our failures,” said Sandra Broderick, HSE Mid West regional executive officer.
The family described their daughter as “a beautiful young girl loved beyond words by her family and friends".
“She would have had her whole life ahead of her but unfortunately it was taken in such a cruel way,” the parents said.
They said Dr Lal gave them the impression a large team of doctors would be assisting him in the theatre — instead two junior doctors were in attendance.
A clinical nurse said she rang vascular surgeon Eamonn Kavanagh during the operation when the complications arose, but Dr Lal declined his help.
Prof Kavanagh expressed surprise Dr Lal had not contacted him about Ms Sheedy’s case or even mentioned it when he had seen him briefly prior to the operation.
In his statement, he said there was a long-standing practice of having two consultants in theatre for complex surgery.
The inquiry heard Dr Lal had continued to work on removing Ms Sheedy’s tumour after she had suffered major hemorrhaging to see the source of the bleeding more clearly.
The consultant claimed not a day goes by that he does think of the teenager and the tragedy which occurred, and also acknowledged there were “lessons learnt".
Proposal for sanctions will be heard on Wednesday.
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