Manchester hospital issues recall message to patients dating back 26 years after shocking findings

A private Manchester hospital has issued a recall message to patients dating back to 1998. It comes as part of a major recall following the exposure of shocking failures by a prolific spinal surgeon who worked at the hospital.

Spire Healthcare is extending its recall of patients to cover all patients who received specific spinal procedures from 1998 by John Bradley Williamson. The spinal surgeon – who worked at Salford Royal Hospital, the Royal Manchester Children’s Hospital and Spire Manchester Hospital – has been shown to have caused numerous cases of severe harm to patients in his decades-long career.

Those cases include a ‘surgical catastrophe’, where 17-year-old patient Catherine O’Connor died from complications during surgery at Salford Royal Hospital. Mr Williamson ‘misled [a] coroner’ over the 2007 death, an investigation found.

READ MORE: The 'surgical catastrophe' that cost a young woman her life

The surgeon’s work across the three hospitals has been under examination, including by internal and independent reviews. Spire Healthcare says it has already carried out a ‘comprehensive recall of patients who underwent specific spinal procedures by Mr Williamson between 2008-2013’.

Mr Williamson stopped performing surgery at Spire Manchester Hospital in 2013, according to the private healthcare group. The group says the five-year period and scope of patients reviewed was ‘in line with the patient recalls carried out by the local NHS Trusts, where Mr Williamson also practised’.

At the end of each phase of a patient recall, Spire says it considers whether additional patients should be contacted. Based on the findings to date, Spire has announced its decision to extend the recall to cover all patients who received specific spinal procedures from 1998, when Mr Williamson started to perform surgeries at Spire Manchester, ‘to ensure that all patients have received an appropriate standard of care’.

Dr Cathy Cale, Spire Healthcare’s Group Medical Director, said: “We are committed to reviewing the care of all patients where concerns are raised. As we near the completion of the review of Mr Williamson’s patients who underwent certain procedures in the last five years that he performed surgery at Spire Manchester, we have concluded we should try to review all his patients that received these procedures.

“We recognise that it will be challenging to carry out a recall dating back to 1998 but we will endeavour to be as thorough as possible and to support those patients involved in the process.”

‘Unacceptable and extremely difficult to justify’ behaviour

The latest review into Mr Williamson’s NHS work was published back in March. The latest review was commissioned by the Northern Care Alliance (NCA), the trust which operates Salford Royal Hospital, in 2022 after a 'significant concern' was raised by staff.

The trust instructed barrister Carlo Breen to undertake an independent investigation 'to investigate how historic concerns and complaints dating back to 2007 relating to this consultant’s conduct, probity and capability had been previously handled and what lessons could be learned'.

On Catherine O’Connor’s case, referred to as ‘Patient A’, Mr Breen stated in the report: "I accept and rely upon the expert evidence of Independent Expert A in concluding that Patient A’s death was caused by the failure of [Mr Williamson] to organise a second consultant for surgery, which compounded the risks and led to higher than usual blood loss."

A decision had been made in 2006, the year before Catherine's fatal procedure, that there should have been two consultant surgeons present for the operation, the report reads. There was another meeting in 2007 before the operation 'where it was agreed that a second consultant surgeon was necessary for Patient A’s operation because of its complexity'.

The lack of a second consultant surgeon during the surgery on Patient A went against the advice given to Mr Williamson before the procedure by other colleagues at Salford Royal Hospital, said the report. Not having a second consultant surgeon was ‘unacceptable and extremely difficult to justify’, in the view of one independent expert who contributed to the latest review.

The expert who provided evidence to Mr Breen said: “The lack of a second consultant surgeon expressly against the advice of the MDT is unacceptable and extremely difficult to justify. That, plus the decision to proceed with an orthopaedic registrar, I believe directly contributed to the patient’s death due to the inevitably slower surgery.

"This decision in my opinion exhibits blatant disregard for the patient’s safety in such a complex case involving a physically vulnerable young person. The sad adverse outcome is predominantly due to poor decision making around fundamental aspects of safe practice.

"It is my opinion that this would in the presence of all the details be the opinion of a reasonably competent expert in this field."

The review also found there was an ‘underestimation of bleeding by the surgeon’ and ‘there was a missed opportunity to abandon surgery earlier which may have enabled control of bleeding and successful resuscitation’ of the patient. Mr Williamson then ‘misled the coroner as to the severity of the quantity of blood lost in Patient A's surgery’, said the review.

Mr Williamson reacted to the report by saying: "There are findings and conclusions with which I do not agree."

Failures to investigate death led to more botched surgeries in the following years

The review also detailed how there were failures to properly investigate the death at the time, with the death being ‘dismissed as an expected complication of surgery’. Those failures to investigate led to more patients being harmed, including one procedure that was 'performed to a substandard level with multiple misplaced screws'. One of these screws caused severe life-threatening haemorrhage due to direct vessel damage, said the report.

In another case, there was a 'failure to proceed with the next phase of the operation for 90 minutes, with no communication with senior colleagues, was unacceptable and could potentially have led to a significant complication with a poor outcome as a result' - with the patient then not being informed of the events that happened in their surgery.

In 2021, an inquiry was launched into the former consultant and his treatment of some 130 patients at Salford Royal. That inquiry by the Northern Care Alliance NHS Foundation Trust (NCA), which runs Salford Royal, found Mr Williamson repeatedly exercised ‘unacceptable and unprofessional behaviour’, carried out botched surgeries with misplaced screws in patients’ spines, and left patients with serious blood loss, long term pain and mobility issues.

On February 29, the children’s hospital shared the findings of its own review, showing it too had patients which suffered ‘severe harm’ after being treated by Mr Williamson. There was no evidence of apologies offered to those patients – and ‘this lack of formal acknowledgement of complications may have contributed to a lack of recognition of their frequency or severity arising through the care’ of Mr Williamson.

The surgeon, now in his 60s, was employed in 1991 before being sacked from the trust in January 2015 following inappropriate behaviour towards a member of staff, reported the Sunday Times. A decorated consultant, Mr Williamson admitted ‘his personal actions were inappropriate’.

During his career, the consultant spinal surgeon had enjoyed a leading position as the head of division for neurosciences and renal medicine from 2011 to 2015, had been an examiner for the Royal College of Surgeons and had been president of the British Scoliosis Society.

What does the surgeon say?

In the wake of the Carlo Breen report, Mr Williamson said: “I have considered the executive summary to the investigation report prepared on behalf of the Northern Care Alliance by Carlo Breen. It covers events between 2006 and 2023 and action taken or not taken by the trust and its predecessor.

“Insofar as it related to the care provided by me, it is important to recognise that standards in many aspects of practice have changed considerably since 2006. I have always made patient care my first priority. I will consider and reflect on the findings of the report. There are findings and conclusions with which I do not agree.”

Spire is currently in the process of identifying the patients to be contacted and will then write to them. If any Spire Manchester patients have questions about the review of their care under Mr Williamson, they can email spirepne@spirehealthcare.com and a member of the dedicated review team will call them back.