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Businessman Dies During Clinical Trial After Surgical Error Leads To Fatal Air Embolism

Narrative Verdict Recorded At Inquest


An inquest jury has heard how a 43 year old Warwickshire businessman died during a clinical trial, after a surgeon wrongly injected air into his knee joint causing a fatal air embolism.

Luigi Belcuore, known as Louis, underwent what was supposed to be a relatively straightforward operation, at the Robert Jones and Agnes Hunt Orthopaedic Hospital in Oswestry, on 20th October 2009.

However the surgery, which had been testing different surgical techniques for treating knee cartilage problems, ended tragically when Professor James Richardson modified equipment without approval and wrongly injected air into Mr Belcuore's knee joint. The tragedy occurred whilst the anaesthetist was absent from the operating theatre.

Following today's narrative verdict inquest in Shrewsbury, a medical law expert from Irwin Mitchell solicitors has called for a full GMC investigation.

The jury and HM Coroner for Shropshire, John Ellery, heard how Mr Belcuore from Morton Bagot near Studley was a keen sportsman and had agreed to undergo the clinical trial on his left knee to alleviate a long-standing cartilage problem.

The father of two young daughters at the time of the surgery, who was the Northern European Sales Manager for American computer graphics giant, Nvidia, had expected to be home from hospital very shortly after the surgery and had set up an office at home so that he could continue working whilst recovering from the surgery.

His widow, Penny, described to the jury how on the day of Louis' operation she received a phone call, not from her husband to say that he was back on the ward, but from Professor Richardson.

She said: "He asked me if I was alone in the house and then suggested I fetch a neighbour to be with me as he had bad news. I knew straight away that something was dreadfully wrong.

"He then told me that Louis had suffered a massive heart attack and had died on the operating table. He started crying down the phone and said he was so very sorry about what had happened. It was a terrible phone call and I had a hard time comprehending what had happened. I was in complete shock."

Just four weeks after Louis' tragic and untimely death, Penny discovered that she was expecting their third child. Sadly Louis never knew that he was going to be a father again. He leaves behind a young family of two young daughters and a son aged 8 months, his widow, Penny, as well as three sisters, and his elderly parents who live in Amalfi, Italy, who are all struggling to cope with his loss.

Victoria Blankstone, a medical law solicitor with law firm, Irwin Mitchell, who is representing Mr Belcuore’s family, said: This was a tragic error which should never have happened. The court heard expert evidence which revealed that even junior doctors would have been aware of the problems associated with arthritic knee joints and the risks involved in injecting air into the human body, so it is difficult to comprehend why a more senior specialist would have decided to inject air in such circumstances.

"We are now calling on the GMC to formally investigate this matter.

Penny Belcuore added: "Life without Louis has at times been almost too much to bear but I have had to find the strength to carry on for the sake of our two daughters and our baby boy. Louis had so much energy – he loved his job which took him all over Europe, he enjoyed football and all kinds of sport, but most of all he loved spending time with his two daughters. The hardest thing of all is that both they, and the son he never even got to see, will now grow up without their Dad."