Independent investigation into the care, treatment and management of Mrs Elizabeth Rourke
Elizabeth Rourke died during routine day surgery carried out by a locum gynaecologist at the Jersey General Hospital in October 2006. Verita's independent investigation identified underlying weaknesses in patient safety systems that may have contributed to her death.Crucially, the hospital's system for recruiting and monitoring locums was weak. As result, it was impossible to determine whether Mrs Rourke's death was due to a tragic mistake by a competent gynaecologist or by someone who was not competent to carry out unsupervised gynaecology surgery and should not have been employed as a locum in the first place.
Verita's independent investigation was commissioned by the States of Jersey in March 2009. The independent investigation followed the trial and acquittal of the locum involved in the case in January 2009. Mrs Rourke's death, the court case and the delay in commissioning the independent investigation until after the trial had ended generated considerable public and political interest, debate and speculation.
Lead investigator Ed Marsden explains: "At the heart of this complex case was the death of a young woman. As independent investigators our job was to focus on the facts so that lessons can be learned and patient safety systems improved."
Verita's investigative team - which included professional advisers on gynaecology and vascular surgery - carried out 66 formal interviews and analysed thousands of pages of notes and records, police and trial transcripts, and all relevant hospital policies and procedures. Verita's report was published on 1 February 2010.