by The family of a famous film make-up artist have urged the coroner to investigate his death amid concerns about his treatment by a physician colleague (PA).
Christopher Tucker died at the age of 81 from sepsis from a bladder infection on December 14, 2022.
A PA at the Royal Berkshire Hospital performed a cystoscopy, an invasive bladder procedure, on him less than 48 hours before his death, despite signs of infection.
The PA subsequently failed to document the need for antibiotics or request them from the ward doctor.
Mr. Tucker’s prosthetics on The Elephant Man inspired the Academy of Motion Picture Arts and Sciences to create an Oscar.
An internal investigation by the Royal Berkshire NHS Foundation Trust found that the PA was not responsible for any errors, and that even if a urology doctor had been available, it was “likely” that Mr Tucker’s treatment would have changed.
But eight senior doctors who examined the report told The Telegraph they disagreed.
Four urology specialists said they would have rescheduled Mr Tucker’s procedure because of the high risk of “life-threatening” sepsis.
There are also concerns about the objectivity of the report, as the name of the associate physician on the review team matches the initials of the PA who provided medical notes to the investigator.
His brother Lynton Tucker said: “Christopher would have wanted this to be investigated, and it would have worried him.
“[He] an artist who was very demanding of himself and as a result he had discerning views. He had a passion for making sure the right thing was done.”
On Monday, peers will vote on a motion that could delay the government’s plan to license the medical regulator, the Medical Council, for this workforce.
Baroness Brinton, the former Lib Dem health spokeswoman, said she intended to raise the “extremely worrying” details of Christopher Tucker’s case at the debate, as they “provide more evidence as to why that there is a risk that the government’s proposals would undermine patient safety”.
It is understood the associate who co-authored the review, and has since left the trust, has not denied carrying out Mr Tucker’s cystoscopy.
The hospital did not object to this apparent breach of NHS protocol, which states that inquiries are not “led by staff involved in the patient safety incident itself” – or by their managers.
A spokesman for the trust said there had been a “full investigation” into Mr Tucker’s case, and “the learning has been shared across the organisation”.
‘Prevarication shocking’
But his niece Catherine Tucker, a professor at the Massachusetts Institute of Technology, said there was “a terrible amount of bias, outside intelligence, a lack of transparency, a lack of plain language – and then the loss of what really killed him.” the report”.
She explained that the bladder procedure was not presented as “something that could be a decision point”.
However, consultant urological surgeon Jude Dockray said it was vital because, “in a patient with recent urosepsis, who shows worsening observations and biochemical markers of infection, the risk of life-threatening sepsis is significantly increased”.
She said: “Personally, given the information provided, in this case I would not go ahead and postpone the procedure until the patient has recovered.”
Having previously declared him fit for discharge, on December 12, the day of his cystoscopy appointment, staff noticed Mr Tucker’s rapid, shallow breathing and blood “getting worse”. Elevated markers of infection were recorded in the last entry on her notes before the procedure.
Eight senior doctors disputed the trust’s decision that “these would not cause the PA to seek further review”.
‘Strict supervision’
Professor Partha Kar, a consultant endocrinologist, said: “There does not seem to have been a discussion of the risks versus the benefits of this invasive procedure, and this is important when we consider what happened next.”
Last month, Dr Janet Lippett, the trust’s Chief Executive Officer, told BBC Radio 4 that senior doctors are “always available to [PAs] discuss cases” – and a hospital spokesperson reiterated this “strict supervision”.
But Dr Matt Kneale, co-chairman of the Doctors’ Association UK, who discussed Dr Lippett on the programme, said, “it is difficult to argue in the trust’s own report whether a urology doctor could have ‘changed the result’. this PA was always supervised”.
He added: “Mr Tucker’s case tragically illustrates the problem with placing PAs in roles traditionally held by doctors.
“But the situation is not unique. Doctors across the country tell us that PAs are performing complex procedures and running outpatient clinics independently.”
The Royal Berkshire NHS Foundation Trust said: “We offer our deepest sympathies to Mr Tucker’s family and our clinical leadership team would be delighted to meet with them if they wish to discuss the case in detail.”
He added that PAs have a “very clear code of practice and strict governance” and are “subject to thorough competency-based assessments” to monitor safety and work standards.
