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Inquest into death of baby boy after life-support machine errors

Child surgery error


The solicitor representing the parents of a 4-month-old baby boy, who died at Birmingham Childrens Hospital, has expressed concerns that a number of failings that became apparent during the course of an inquest into the post child surgery care have not been adequately reflected in today's verdict.

Children's surgery solicitors

Birmingham coroner, Aiden Cotter, heard during the three-day inquest that four-month-old Thomas Smith, from the Longbridge area of Birmingham who had Downs Syndrome, had been admitted to the Childrens Hospital for surgery to take place on 10th December 2004 to repair a heart defect. A narrative verdict was returned.

Following surgery he was put on a ventilator, which during the course of his post-operative care malfunctioned. Thomas stopped breathing and as a consequence needed resuscitation. After more than 140 minutes of resuscitation, the decision was made to put him back onto a bypass machine.

Post child surgery care negligence

The following day, during the process of cleaning the by-pass equipment the machine was inadvertently switched off. The hospitals only trained operator had been sent home, and the remaining staff were unsure how to restart the machine. In attempting to restart it, the machine was accidentally put into reverse pushing oxygenated blood back into Thomas body. The inquest heard that Thomas had suffered a cardiac arrest as a result of the ventilator having malfunctioned and that this catastrophic event had in all likelihood caused irreparable damage prior to being placed on the by-pass machine.

Over the next two days Thomas failed to respond to treatment and his condition deteriorated. Sadly he died two days later on 15th December 2004.

Child surgery lawyer

The family's solicitor, Mandy Williams, from the Birmingham office of national law firm Irwin Mitchell, said: It is the family's view that the narrative verdict given by the Coroner today failed to address a number of key issues of concern that were heard in evidence during the inquest. The reason for the ventilator failure has not been established which we consider is of paramount importance in view of the fact that these machines are still in operation.

In addition an independent Consultant from another Trust that was asked to review the incidents at Birmingham Children's hospital, highlighted his concerns in respect of whether the resuscitation procedures that were implemented were as adequate and timely as they should have been. This is not reflected in the verdict.

Another issue that we consider has not been fully illustrated is the incident relating to the bypass machine. In evidence it was accepted that on balance this is likely to have contributed to the damage that Thomas suffered albeit to a far lesser degree. Only one perfusionist was available at the Trust to monitor the workings of a machine that was known to require constant trained monitoring. It was the view of the Trust themselves that inadequate resources are available to provide the specialist support that patients such as Thomas need. We do not consider that today's verdict fully reflected these issues that are of paramount importance to all paediatric cardiac patients and the clinical staff that work in the current system.

"The family are aware that a civil claim can be pursued against the hospital and are currently considering this option.

Thomas mother, Lisa Weale said: My partner, Jason and I have been left completely devastated by the death of our only child. Although heart surgery is a major operation, we were given every reason to believe Thomas had a chance of making a full recovery. The following morning the medical staff told us that Thomas was doing really well and they were pleased with his progress.

I believe that Thomas was completely let down by the hospital in a number of ways. My primary concern relates to the ventilator Thomas was attached to. It appears to have been either faulty or had been inappropriately handled. I feel very strongly about this and cannot understand why nobody reacted when Thomas stopped breathing and I had to tell his nurse that his chest had stopped moving. I am also concerned as to why unqualified staff were handling the bypass machine and consequently unable to react instantly in an emergency situation. I believe Thomas should have been referred for his heart scan earlier because I understand this improves chances of recovery. It is my belief that but for these errors, Thomas would still be alive today.