A HEALTH board “put patients at risk” from a surgeon after ignoring external warnings he was a “poor doctor”, a report found.
NHS Tayside carried out a due diligence review into Professor Sam Eljamel, who it employed as a consultant neurosurgeon from 1995 until retiring in 2014, and its findings were published on Thursday.
A legal claim was made in February 2013 and the board launched a probe in June, with the Royal College of Surgeons (RCS) carrying out a review following a complaint.
In the next six months, Eljamel operated on 111 patients, and the NHS received a total of nine complaints and settled two of them, branding supervision measures “inadequate” in a report.
A statement from NHS Tayside said: “This was indirect supervision which means he was not supervised directly in the operating theatre by another neurosurgeon.”
The NHS Tayside report said: “These patients were placed at potential risk of harm due to the inadequacy of the supervision arrangements.”
Dr Pamela Johnson, NHS Tayside executive medical director, told a board meeting on Thursday: “Police Scotland were involved at some stage. I can’t give you any more information than that.
“I have written to the patients who had their operation between June 21, 2013 and December 10, 2013 to inform them about the findings of the review and to sincerely apologise on behalf of the board.”
She apologised to patients and called on anyone who has concerns to get in touch through the liaison response team at TAY.patientliaisonresponse@nhs.scot.
Scottish Labour has backed patients’ calls for a public inquiry and for the NHS Tayside board to resign.
An investigation was dropped in 2014 when the surgeon retired, which Dr Johnson said was a “missed opportunity for learning” which would not happen today.
The RCS warned about his “probity” in October 2013, mid-way through the supervision period, and said there were signs he was “a poor doctor” – however NHS Tayside made no escalation of supervision.
A staff member lodged a complaint during this time, but there “was no outcome or action identified”, the report said.
Eljamel was allowed to continue working for another three months, before finally being suspended in December 2013.
He retired in 2014 which ended the investigation, and in 2015 he voluntarily removed himself from the GMC register unchallenged by the board, which could have intervened.
The report said after he left NHS Tayside “a website stated the surgeon was a clinical fellow, a qualification he had earned from Connecticut University while working at Hartford Hospital in Connecticut, USA”, prompting concerns.
NHS Tayside said there was no evidence of this on his CV but the qualification would not have been a requirement for the post.
A decade later, patients who were referred to chronic pain clinics following flawed procedures including operations for sciatica, are demanding a public inquiry, with two legal cases ongoing and 12 settled.
NHS Tayside held the due diligence review to “assist the medical director in their assessment of the adequacy of procedures to detect signals of concern relating to the practice of Professor Eljamel”.
It also looked at the trust’s response to external scrutiny, and the current policies in place.
Between 1995 and 2023, some 98 complaints were logged, although a computer systems change meant additional ones may have been lost and no minutes were kept of staff meetings.
It added: “All systems were comparatively immature compared with current systems.”
The Scottish Government has said it is exploring a number of options for former patients of Prof Eljamel with the intention of establishing a “person-centred, independent review of individual cases”.
There were three complaints in 2011 and 2012, which rose to eight before he was suspended, and 84 complaints were logged afterwards including some from 1996.
NHS Tayside said there was no evidence Eljamel reported himself for “complications”, which he would have been obligated to do.
The report said: “Some of these systems were in their infancy and some were reliant on self-reporting of clinical outcomes.”
Concerns were raised about “clinical performance” at a meeting in June 3, 2013 but “it was concluded by the medical management that Professor Eljamel had reflected and altered his practice significantly”.
It added: “Other issues would be dealt with within the surgeon’s appraisals and revalidation” with no plan of action.
On June 21, a meeting was held due to more complaints regarding “poor medical treatment” and “errors in procedures”.
Despite this, Eljamel was allowed to continue ward rounds and on-call duties for six months and was not supervised in the operating theatre, which was branded “inadequate” in the review.
The report said: “There was inadequate senior input which resulted in inadequate assessment of risk and consideration of patient safety.
“There is no documentation to suggest that suspension or restriction to practice was considered.”
The report found: “Indirect supervision was inadequately monitored and therefore NHS Tayside was not adequately supervising Professor Eljamel’s practice, despite having identified a potential concern.”
It found the “receipt of the interim letter from the RCS was a missed opportunity”.
It added: “There is no documentation of consideration of the supervisory arrangements being escalated at this further opportunity in October 2013.”
Scottish Labour deputy leader Dame Jackie Baillie (above) said: “Those who failed to end this scandal must be held to account – we need a full public inquiry and we need Government ministers to come before the Scottish Parliament immediately and explain what they knew about this scandal and when.”
Health Secretary Michael Matheson said: “This is a thorough report and lays bare some of the failings in NHS Tayside’s response to concerns over Professor Eljamel.
“It is clear from this review that these were not acted upon with the urgency they deserved.
“What is important now is that those people directly affected are supported to find the answers they need, and that both staff and patients across Scotland know lessons are being learned.
“For that to happen properly, I have been clear that this needs investigation independent of both NHS Tayside and the Scottish Government.
“We will provide more details on this shortly.”
