Three Weeks to Act on a Nurse’s Patient Safety Concerns

For three weeks after his surgery, a patient at the Royal Oldham Hospital (England) had no bowel movement and was in increasing pain. The ward sister kept raising patient safety concerns with the surgeon who'd operated on him. She described him as unconcerned.

On September 15, 2020, she stayed on duty after her shift was supposed to end. She'd already gone around him to the ward manager, who escalated it further. A meeting was held. She was told they'd speak with the consultant and sort it out.

A CT scan was ordered that day. She stayed until someone read it. At around five in the afternoon, a different consultant surgeon reviewed the scan, compared it against the operation notes, and decided the two didn't match. He took the patient to the operating room.

What he found was that the patient's small bowel had been connected to the stomach the wrong way around, forming a closed loop. Yikes. Even as an engineer, that sounds like a horrific mistake and situation to be in. Whatever left the stomach came back into the stomach. The patient had no bowel movement since the first operation on August 25. The GMC's expert witness told the tribunal that the patient would have died without that second surgery.

All of this comes from the Medical Practitioners Tribunal Service determination published on July 22, 2026, which erased Dr Yasser Adly Abdel Rahman from the medical register. He didn't attend the hearing and wasn't represented.

A quick note on the British terms, since most of my readers are in the US. A consultant is roughly an attending physician. A registrar is closer to a senior resident. A ward sister is close to a charge nurse. A locum is a temporary physician filling a staffing gap, the way locum tenens or agency coverage works here.

Patient safety concerns shouldn't depend on one person's persistence

The patient did get to the right surgeon. It took three weeks.

According to her witness statement, the ward sister noted that the patient still had no bowel movement when she saw him on September 1, 2, 9, and 15. She raised his pain with the consultant on September 8. On another occasion she and a registrar had agreed on a plan to give a contrast study, and she said the consultant shut it down in an angry tone. She believed that if the plan had gone ahead, they'd have known sooner that something was wrong.

So she went around him. It took three weeks, a ward manager, a clinical director, a medical director, a meeting, and her staying past the end of her shift to make sure the scan actually got read by someone who would act on it.

That is not a strong escalation path. That's a weak one that managed to work out because one person wouldn't drop it.

In a Toyota plant, when a team member pulls the andon cord, a team leader is expected to respond right away, and the response is help. In Lean Hospitals I wrote about Virginia Mason's patient safety alert system and the TeamSTEPPS escalation steps, both of which exist because the alternative is exactly this: a concern that has to survive three weeks and four layers of hierarchy on the strength of one person's willingness to spend her own credibility.

That's also why I keep arguing that telling people to be brave is the wrong prescription. This ward sister was brave. It shouldn't have been necessary.

The hospital's own report said there was no framework for locums

The tribunal found that he failed to seek help from a consultant surgical colleague before operating. It did not find that he failed to seek help from the regional specialist upper GI center, and the reason is the interesting part.

The investigation report from Northern Care Alliance, the NHS trust that runs the hospital, accepted that there was “an absence of an organisational framework” for the practice, supervision, and mentoring of locum surgeons.

That screams “system problem.” One that might not have caused a problem every day, but it finally burned everybody involved.

The GMC's expert agreed there was no evidence that Dr Abdel Rahman had been told what support was available to him. The tribunal decided it couldn't call it a failure to contact a center he may not have known existed.

He was a locum consultant and wasn't on the GMC's specialist register, the list of doctors approved for consultant-level practice in a specialty. He was a few days into the job, operating out of hours in the first year of the pandemic on a case the expert described as extremely difficult.

He did get help, in a way. There was major bleeding, the vascular team was called, and a locum vascular registrar came to the operating room and stayed to assist. The two of them discussed the options and agreed on the approach. That's help that showed up because someone was already in the room for another reason. It isn't the same thing as knowing who to call.

If a hospital's staffing model involves dropping unfamiliar senior clinicians into emergency work, someone has to design the path to help on purpose. It won't form on its own in three days.

The imaging didn't catch it either

Four contrast studies were done after the surgery. On August 26, none of the contrast passed beyond the stomach. On August 27, the report said there may be some diluted contrast in the ascending colon, which the expert suggested gave false reassurance. On September 8, the contrast again stayed in the stomach. The September 15 CT report described Roux-en-Y loops, and the radiology expert concluded the closed loop hadn't been recognized or reported by the reporting radiologist.

That doesn't get the surgeon off the hook. His job was to ask why his patient was in escalating pain three weeks after surgery. But he wasn't the only person who looked at this patient's images and didn't see it.

He never considered that something had gone wrong

On September 11, he met the patient's parents and told them the procedure had gone well and that he'd send their son home once the pain was controlled. The tribunal found the clinical and radiological evidence didn't support that. The expert's summary was that at no time did he consider something might have gone wrong surgically.

In his written response, he called the investigation a “witch hunt” and said colleagues had lied.

I don't know what was going on for him. It does seem, though, that in a lot of hospitals, admitting you might have gotten a surgery wrong is about the most expensive thing a surgeon can say. That's not a defense of him. He also breached the conditions later placed on his registration, and the tribunal found he was dishonest with the GMC about when he started a job in Ireland, which is a choice rather than fear. But when an organization wants people to consider that they might have erred, the cost of saying so has to be survivable. It usually isn't.

Good character is not the same as a good record

The tribunal directed itself that Dr Abdel Rahman was a man of good character, meaning no convictions, cautions, or previous adverse regulatory findings. It also reminded itself that good character isn't a defense and that its significance shouldn't be over-inflated.

That second half is the part I'd put in front of leaders. A clean record tells you what got recorded: nothing. A long career with no complaints can mean the work was good. It can also mean nobody was counting, or that the people who noticed didn't believe a report would go anywhere. You can't tell which from the number.

If someone on your unit raised a concern about a patient today and the consultant waved it off, how long would it actually take before a second set of eyes looked? I don't mean what the escalation policy says. I mean how long it would take.