Digital copy of a Report for the Minister for Health and Social Services, States of Jersey by Verita titled An independent investigation into the care, treatment and management of Mrs Elizabeth Rourke. For Anne Pryke's Witness Statement to the Inquiry dated 22 September 2015, see C/D/AW3/B1/1/WS000638.

View WD007543.pdf | Download WD007543.pdf




January 1st 2010 - January 31st 2010

Scope and Content

Contents include an introduction, terms of reference, executive summary and recommendations, and details of the approach, structure and of those involved in the Report. Report includes three parts: • Part One. Describes the obstetrics and gynaecology department in 2006; sets out the outcome of the criminal case against Dr Moyano; describes the care, treatment and management of Elizabeth Rourke before and on 17 October 2006; explains the background to Dr Moyano's recruitment and employment; comments on the allegations made against Mr Day and Dr Moyano during the criminal trial; and comments on the hospital's interim serious untoward incident investigation of Mrs Rourke's death. • Part Two. Describes the Jersey General Hospital generally, including its stand-alone nature and progress on introducing governance and comments on the management structures including the involvement of clinical staff in running the hospital; explains more about the surgical directorate; and provides background information about the day surgery unit. • Part Three. Sets out the factors that contributed to Mrs Rourke's death using a model of incident causation, referring to findings and comments in parts one and two. Also includes seventeen appendices titled: Terms of reference; Letter from Minister to the investigation team; Documents reviewed; Royal College of Anaethetists report; Chronology; Dr Moyano's CV and references; Surgical procedures involving Dr Moyano; Operation list of 17 October; Letter from Graham Prince to Rose Naylor; SUI recommendations- HSSD progress report; UK approved service providers; WHO pre-operative/surgical safety checklist; Notes on the creation of an operating list; Notes on the pre-admission assessment; Notes on the day surgery procedure; Notes on medical training and qualifications; and Team biographies.


Adams, Sally, Dr
Ahmad, Khalid, Dr
Allardice, James
Allan, Lindsey, Professor
Andrade, Brian
Ask, Mr
Badri, Al, Dr
Bappa, Lawal, Dr
Baudains, Marnie
Beechey, Christopher
Bell, Professor
Belligoi, Mike
Bewley, S, Dr
Body, Angela
Bower, Sarah, Dr
Boyes-Varley, Sarah
Bree, Andree
Butcher, Will
Carnall, Ruth
Clifford, Ms
Clifford, Paul
Coleman, Peter, Dr
Coll, Oriol, Dr
Day, John
De Gruchy, Peter
de la Haye, Julie
Dnes, Irina, Dr
Dumbrill, Douglas
Elfara, Ali, Dr
Fenwick, Daniel
Field, Lilliane, Dr
Forbes, Professor
Gales, Tom
Gallagher, Mrs
Gindill, Judith
Govan, Dr
Haley, Marita
Hanafin, Terry
Hanson, Tanya
Harding, Ms
Harley, Jackie
Head, K
Hyett, J
Ilangovan, Chelliah, Dr
Ingram, Nicholas
Jarvis, Mr
Jouault, Richard
Journeaux, Moyra
Kelly, Ms
Kynman, Gary
Lane, Richard, Dr
Langford, Ms
Le Cocq, Timothy
Le Feuvre, James
Leed, Karina
Lighten, Anthony
MacLachlan, Neil
Marsden, Ed
Martins, Lis
McLaughlan, C
Mechen, Derek
Mottram, Suzanne
Moyano, Dolores, Dr
Naylor, Rose
Nelson, Fiona, Dr
Nelson-Piercy, C
Nikolaides, Mr
Nisbet, Pat, Dr
Penna, Leonie
Perchard, Jim, Senator
Pollard, Mike
Prince, Graham, Dr
Purcell-Jones, Gari, Dr
Pryke, Anne Enid, Deputy
Pycraft, Wendy
Reason, James
Rice, Mr
Robertson, Ms
Roche, Professor
Rourke, Bob
Rourke, Elizabeth
Scott-Moncrieff, Lucy
Sheenan, Professor
Siddiq, Mohamed
Siodlak, Martyn
Smith, Sam, Detective Sergeant
Southall, Peter, Dr
Stone, Michael
Sullivan, Liezl, Dr
Syvret, Stuart, Senator
Taylor, Chad, Dr
Thomsen, Regina, Dr
Tinston, Robert, Professor
Torrance, Elaine
Tucker, Sir Richard
Upsdell, Stephen
van Besouw, Jean-Pierre, Dr
Wijesinghe, Lasantha
Williams, Gbolahan, Dr
Wilson, Malachy, Dr
Woolfson, Julian
Association of Cardiothoracic Anaesthetists
Association of Chief Police Officers
Association of Surgeons
Beauport Ward, Jersey General Hospital
Board of Examiners
Bourn Hall, Cambridge
Bournemouth University
British Medical Journal
Capita Health Solutions
Care Quality Commission
Chief Minister's Department
General Medical Council
Guys and St Thomas' Hospital
Gwyneth Huelin Wing
Hallam Street Hospital
Harris Birthright Research Centre for Fetal Medicine
Health and Safety Executive
Health and Social Services
Health Protection Agency
Hospital Clinic of Barcelona
Hospital Cruz Roja
Hospital Sta Creu i Sant Pau
Hospital Universitari Sant Jan Déu
Hotel de France
Jersey Evening Post
Jersey General Hospital
King's College Hospital
Medical Protection Society
Misioneras de Nazareth School
National Clinical Assessment Service
National Health Service
Open University
Paseo Vall d'Hebron
Portelet Ward, Jersey General Hospital
Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust
Royal College of Anaesthetists
Royal College of Obstetricians and Gynaecologists
Royal Court
Royal Marsden Hospital
St George's Healthcare NHS Trust
St Thomas' Hospital
States of Jersey Police
University Autonoma of Barcelona
Vall d'Hebron University
Vascular Surgery Society of Great Britain and Ireland
World Health Organization


Barcelona | Cambridge | Jersey General Hospital | 53, Frith Street | Morier House | Peter Crill House | Salisbury | South Africa | Spain | committees of inquiry | deaths | departments | deputies | doctors | evidence | gynaecology | Hospitals | IJCI | investigations | Letters | manslaughter | ministers | nurses | reports | Surgery | trials


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