Coventry Neurosurgeon criticised after Brain Tumour Patient Dies Unnecessarily

Written by Clinical Negligence on March 14, 2018

Serious concerns have been raised about the competency of Consultant Neurosurgeon and Spinal Surgeon, Mr Hussien El-Maghraby, whose surgical technique was described as ‘appalling’ and “completely contrary to how one does neurosurgery”.

Mr El-Maghraby is employed by University Hospitals Coventry & Warwickshire NHS Trust and also works on a private basis at the Woodland Hospital in Kettering.

In 2016, Mr El-Maghraby operated on Mr Stephen Bridgeman to remove a benign brain tumour. During the surgery Mr Bridgeman suffered an internal bleed causing irreparable brain damage. He was left in a vegetative state and subsequently died. Upon review of his medical records, it was found that 20 minutes of the 3 hour procedure performed by Mr El-Maghraby had been filmed. An independent expert Neurosurgeon instructed to review the footage heavily criticised that the “very rough” way the surgery was performed and was appalled that the tumour had been removed in one piece. The expert concluded that Mr Bridgeman should not have died.

Concerns had previously raised about Mr El-Maghraby’s ability to perform complex surgery in 2014 after he had operated on Ms Doreen Dunn from Coventry. Ms Dunn also underwent surgery to remove a benign brain tumour. However, pathology results subsequently revealed that Mr El-Maghraby had also removed a large chunk of healthy tissue from Ms Dunn’s brain. Ms Dunn sadly died a few days after the surgery.

Following a review by the Royal College of Surgeons (RCS) in September 2017 Mr El-Maghraby was found to be competent at performing routine brain cancer surgery, but prevented from undertaking complex spinal operations and brain surgery performed whilst the patient is awake until he has completed further training and mentorship. However, Mr El-Maghraby has indicated that the General Medical Council are taking no further action and there are no restrictions on his medical licence.

If you are concerned that you or a loved one may have suffered a brain injury as a result of substandard brain surgery or other medical treatment please contact Catherine Bell at or telephone on 01865 781140, for a free and confidential discussion about your options.

Chris Adams, who was head of neurological surgery at the former Radcliffe Infirmary in Oxford, said: “This is very, very rough surgery. In fact I’m appalled by it frankly. “I have never seen this sort of tumour removed in this way – [it has] just been pulled out in one piece.  “It’s just completely contrary to how one does neurosurgery.”


The catastrophic effects of delay in diagnosing meningitis

Written by Clinical Negligence on March 8, 2018

Meningitis is inflammation of the membranes that surround and protect the brain and spinal cord. Anyone can be affected and the most common forms of meningitis are bacterial and viral.

Symptoms include pale and blotchy skin with a rash that does not fade when compressed with a glass, stiff neck, dislike of bright lights, fever, cold hands and feet, vomiting, drowsiness and severe headache.

Sadly 10% of bacterial meningitis cases are fatal and of those who do survive, one in three suffer complications including brain damage and hearing loss. Viral meningitis is rarely life-threatening but can cause long-lasting effects, such as headaches, fatigue and memory problems. Meningitis can also lead to sepsis.

 Early diagnosis and treatment of meningitis is crucial, and delay in diagnosis can result in catastrophic consequences for a patient and their family.

Today there is a sad case in the press of 6 year old Layla-Rose Ermenekli, who was taken to Royal Oldham Hospital in Greater Manchester by her mother Kirsty, on 3 February 2017 at 8.30pm. She presented with symptoms of high temperature, lethargy, sickness and a rash.

She was initially assessed by a Nurse but was not seen by a doctor until 10.45pm. Dr Rajanna, a senior A&E doctor, missed the symptoms of meningitis but noticed a mark on her right hip which he assumed to be a bruise and failed to document in her medical records.

A junior doctor, Dr Buck tended to Layla-Rose at 1am and noticed a small rash near her left hip, which did not go away when pressed. She spoke to Dr Rajanna about this. He said that he had also seen it, and other rashes on her body, but was not concerned. He reassured Dr Buck that a paediatric review was sufficient and that no further assessment was required.

Layla-Rose was transferred to a children’s ward almost five hours after admission to hospital. There it was realised that she in fact meningococcal meningitis and septicaemia (sepsis). Unfortunately the correct diagnosis had come too late, and she sadly passed away.

Dr Rajanna later told other doctors he had not noticed any rashes on Layla-Rose’s body. Dr Buck attempted to speak to Mr Rajanna about this, however he claimed that he did not think that the mark was a non-blanching rash to be concerned about. Dr Rajanna went on to allege at the inquest that Layla-Rose’s mother had told him that she had run into a table, causing the bruise to her hip.

An internal investigation by the hospital found that Dr Rajanna did not recognise the “bruise” as a Purpuric Rash (an indicator of meningococcal sepsis), and failed to identify the advanced nature of the sepsis resulting in a delay in diagnosis for three-and-a-half hours. A second opportunity was also missed when the rash was noted prior to transfer and escalated but Dr Rajanna’s false re-assurance that this was not a new finding resulted in no action being taken. The report confirmed that treatment opportunities were missed.

Coroner, Lisa Hashimi, recorded a narrative verdict at the inquest of Layla-Rose’s death this week. She confirmed, “…there was a catalogue of errors and omissions, delayed medical review, lack of observations, assumptions made and the misdiagnosis of the rash as a bruise.” She concluded, “The golden hour and opportunity to instigate treatment was missed. I don’t accept Dr Rajanna’s evidence and explanation and I believe he may have made incorrect.”

Freeths has expertise in clinical negligence cases relating to delay in diagnosis of meningitis and other serious infections.

If you, or a loved one, have been affected by meningitis and you believe that opportunities were missed then we may be able to help you.  Please do not hesitate to contact us for a free initial discussion:

Claire Cooper: 0845 274 6830

Naomi Solomon: 0845 030 5742

claire naomi

GP Turned 5 Year Old Girl Away Hours Before Her Death

Written by Clinical Negligence on March 2, 2018

Ellie-May’s mother, Shanice Clark, arranged for an emergency appointment at Grange Clinic in Newport after her daughter began wheezing and was sent home from school. The surgery provided an emergency slot 25 minutes later at 17:00, which Shanice accepted while telling the receptionist that she might be late as she needed to make childcare and travel arrangements at short notice.

Shanice and Ellie-May arrived at the surgery at approximately 17:05 and were then held up in a queue at the reception desk. The receptionist informed the GP, Dr Joanne Rowe, of Ellie-May’s arrival at 17:18. By this time, however, Dr Rowe was already with another patient. She said in the circumstances she would not be able to see Ellie-May. Shanice was then told by the receptionist to return the following day because she had breached the surgery’s “10 minute rule.” The coroner heard this was the first time the rule had been imposed on an emergency appointment.

Shanice was understandably very angry and upset but took her daughter home where she put Ellie-May to bed and checked on her frequently. Around 22:30 that evening, however, Ellie-May lost consciousness and turned blue. Shanice called 999 and Ellie-May was rushed to Royal Gwent Hospital where, tragically, she died soon after due to bronchial asthma.

The senior coroner for Gwent, Wendy James, concluded that Ellie-May “should have been seen by her GP that day” and was “let down by the failures in the system.” The coroner found it was “unacceptable” that no clinical assessment or advice was provided for Ellie-May on the day she first presented at the GP surgery. To make matters worse, neither the receptionist nor the GP asked why Ellie-May had come in for an emergency appointment or offered any guidance on what Shanice should do if Ellie-May’s condition deteriorated. Neither did they offer an alternative appointment with another doctor. Dr Rowe did not even offer to see Ellie-May at the end of the day after she had finished with her other patients.

The coroner therefore found that the opportunity to provide “potentially life-saving treatment” was missed.

If you or a loved one have suffered as a result of negligent primary care, please contact our team on the details below.

Adrian Denton, Clinical Negligence Associate

+44 (0)845 166 6258 /

Phil McGough, Clinical Negligence Executive 

+44(0)845 050 3290 /

PM Announces Review into Public Health Scandals

Written by Clinical Negligence on February 27, 2018


The Prime Minister, Theresa May, has announced a review into three public health scandals which have made the headlines in recent months.

Campaigners have been fighting for years about the harmful side effects of Primodos, vaginal mesh implants and sodium valproate. Public authorities have largely ignored widespread and significant concerns raised in relation to birth defects and life-changing damage to women caused by such treatments.

The review will look into how the UK authorities responded to the concerns raised by those affected and if the government deems it appropriate, public enquiries into each of these issues could be undertaken.

Theresa May recognises that there is an issue with our regulatory and healthcare system which needs to be addressed and a ‘more understanding response’ is needed when patients raise concerns. The review will be carried out by Baroness Julia Cumberlege who stated it is ‘essential’ that our healthcare system ‘promptly learns and makes changes’.

clinical neg, woman, uterus, female problemsWhat are the issues? 

Primodos was prescribed by GPs in the 1960s and 1970s to detect pregnancies in women by inducing a menstrual-like bleed in non-expectant mothers. Complaints have been raised that the drug caused children to be born with severe physical abnormalities, such as shortened limbs and spinal defects. Findings report that at the time, UK regulators warned the German manufacturers there was a 1 in 5 risk in malformations in children after taking Primodos however it was eight years before warnings were actually placed on packaging. Investigations also reportedly reveal that the drugs were never tested before being given to women – not even on animals. Today, one Primodos dose is the equivalent of 13 morning after pills or 40 oral contraceptive pills. It is estimated that 1.5 million women in the UK were given Primodos in the early stages of pregnancy.

Campaigners believe that women should have been warned about the dangers of sodium valproate as long as 40 years ago. The drug was prescribed by GPs to treat epilepsy, bipolar and migraines. Sodium valproate reportedly carries an 11% risk of causing birth defects and a 40% risk of causing developmental problems in babies whose mothers are given the drug during pregnancy. It is alleged that these risks were known to regulators when considering licensing sodium valproate for the control of seizures in epilepsy but that they deliberately decided not to publish this information on the package insert.  It is estimated that approximately 20,000 children in the UK have been harmed by sodium valproate.

A vaginal mesh implant is treatment used in women to ease incontinence and support organs which have prolapsed after birth. The surgical treatment was introduced in the 1990s in order to improve quality of life however it is estimated that around 10% of those treated have suffered life-changing side effects for example: permanent pain, the inability to work, walk or have sexual intercourse. Complications have arisen due to the mesh curling, twisting and cutting through tissue. Campaigners have called for a ban to be imposed on the polypropylene material.

Theresa May’s review should be extended to the concerns raised over the delay in warning doctors and patients about the contamination of the Sorin 3T heater-cooler machines. The machines, manufactured in Germany, are used during heart surgery but have been found in recent studies to cause an infection known as Mycobacterium chimaera which has led to death in some cases. Public Health England suspects that similar machines may also be contaminated.

If you or a loved one believe you have suffered as a result of negligent treatment, please contact our team for a detailed discussion.