Medical Mistake Claims - Simpson Millar LLP

Fatal medical mistake during keyhole surgery

Author: Neil Fearn  Bullet  Dated: 15/04/2013

An inquest has heard how a 16 year old boy died after keyhole surgery when a surgeon pierced a major vein using the wrong instrument due to 'great pressures over delays'.

The boy died during a routine operation when a surgeon allegedly pierced a major vein after using the wrong instrument, an inquest heard. He suffered multiple organ failure during what was supposed to be a ‘low-risk’ 40-minute procedure at Birmingham Children’s Hospital.

An inquest heard that the boy died after a surgeon allegedly used a sharp surgical instrument called a trochar instead of a blunt one, during minor keyhole surgery - a trochar is a medical instrument with a sharply pointed end used to introduce devices such as drains and tubes inside the abdomen.

The inquest heard the details of the surgery from a report read out by the coroner. The report comprised minutes of a meeting between the hospital and the boy's relatives, following an investigation by the hospital.

The jury heard how the trochar pierced a major vein which led to a fatal gas embolism which occurs when air bubbles block blood flow in a major artery, causing massive blood loss and cardiac arrest, the court heard.

Medics battled for more than 2 hours to resuscitate the boy, administering 31 pints of blood in a bid to stem the bleeding.

He was due to undergo a laparoscopy which is a type of surgical procedure that allows a surgeon to access the inside of the abdomen and pelvis without having to make large incisions in the skin. It is also known as keyhole surgery.

Laparoscopy is minimally invasive. This is made possible with an instrument called a laparoscope which is a small tube that consists of a light source and a camera. The camera relays images of the inside of the abdomen or pelvis to a television monitor.

The surgeon makes a small incision in the skin and passes the laparoscope through it to study the organs and tissues inside the abdomen or pelvis.

The operation was led by the hospital’s clinical director for surgery, and giving evidence at the inquest he claimed that he performed the surgery with a piece of equipment he was not comfortable with due to 'great pressure' put on him to reduce delays at the hospital.

He also admitted to the hearing that he had made the fatal incision, which killed the boy. The Doctor told the jury: "Before the surgery I was informed that the reusable blunt trochar I had requested was not available but that a disposable plastic blunt trochar was". He went on to say that "there is great pressure to reduce delays at Birmingham Children's Hospital and I felt under pressure not to delay the operation so said I would go ahead as long as they made sure it was a blunt trochar rather than a sharp one".

Whilst Laparoscopic surgery is very common and is generally regarded as very safe it should be remembered that there's no such thing as a totally risk-free investigation or operation.

The risks of laparoscopy include accidental damage to the bowel, bladder, uterus or major blood vessels which would require immediate repair by laparoscopy or laparotomy (uncommon). However, up to 15% of bowel injuries might not be diagnosed at the time of laparoscopy.

Having regards to the known risks associated with laparoscopic surgery it is not always possible to establish that the damage was caused by substandard care, as in this boy’s case. However, the failure to immediately recognise and repair the damage during the procedure would usually be a mistake that can result in more extensive surgery, permanent scars and a prolonged recovery with the possibility of revision surgery in the future.

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