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Patient’s death prompts check on equipment at Bournemouth Hospital
NEW checks on life-saving equipment have been introduced at the Royal Bournemouth Hospital following a patient’s death.
Lawrence Hill, 59, received dangerously low levels of oxygen and anaesthetic during an emergency operation at the hospital earlier this year when a fault developed in a machine.
The problem with the anaesthetic machine was only detected towards the end of the operation, during which time Mr Hill had been without adequate levels of oxygen for 30 to 40 minutes.
In a statement after a Bournemouth inquest, Mr Hill’s family said: “We still have concerns that these machines are still is use at the hospital.”
A pathologist told the Coroner’s Court that while the cause of Mr Hill’s death was due to a number of natural causes, he believed the faulty Drager anaesthetic machine did contribute towards his death in some way. Mr Hill had been suffering from vascular disease and had undergone a series of operations and procedures.
Dr Lasantha Wijesinghe, a consultant surgeon at RBH, said Mr Hill underwent a right vein graft on June 12 this year but developed bleeding in the leg on June 17 when the graft had come adrift.
Dr Wijesinghe was called in and rushed Mr Hill to theatre and managed to stop the bleed.
Consultant anaesthetist Dr Robert MCormick also rushed to theatre to help Mr Hill who was “bleeding to death”.
Dr McCormick said Mr Hill’s body had gone into such shock that it was decided to anaesthetise him. He said he later discovered the machine had been administering an extremely low oxygen level because one of two vaporisers was not sealed properly and a fracture had occurred in one of the flow sensors.
The doctor explained that no operations had been scheduled for that theatre over the weekend, with all emergency cases to be referred to Salisbury Hospital, and there was simply no time for him to check the machine prior to the operation, which is normal.
“I wish I had stopped for a couple of minutes to check it but that wasn’t an option. My only priority was resuscitating (Mr Hill) who was about to die.”
He said it was only after that the faults were discovered in the machine and despite enquiries with the manufacturers no one had been able to tell him how the machine was able to deliver such low levels of oxygen while operating as it did.
But he said they were to be replaced after he had lost “faith” in it and the hospital trust had changed procedures so all the Drager machines are checked daily.
Pathologist Dr Hussein said Mr Hill died from shock, extensive bleeding from vascular anastomosis site, and bi-lateral femerol artery narrowing treated surgically.
He also found two secondary causes – ischemic heart disease and the failure of the anaesthetic machine. Giving a narrative verdict, Coroner Sheriff Payne said he could not give a verdict of natural causes and instead said: “The lack of oxygen contributed to but did not cause his death.”
‘We’re concerned machines are still in use’
“As a very popular member of the community and a grandfather, our father will be very sorely missed and we are devastated by his death.
“The circumstances surrounding his passing have made this more difficult.
“Although we are comfortable with the Coroner’s verdict we still have concerns that these machines are still in use.
“We do not feel that any doctor or patient should be put in the position where this failure is a risk.
“We are thankful to the doctors involved for their commitment and honesty, in particular Dr McCormick whose honesty and integrity transcend these difficult circumstances.
“We have met the medical director who is addressing our concerns.”
- The Royal Bournemouth Hospital’s medical director Dr Mary Armitage said: “We are deeply sorry for the additional stress this has caused Mr Hill’s family and friends at such a difficult time.
“Ensuring the safety of patients is the number one priority for all of our staff. Following a thorough internal investigation additional checks on equipment are in place to ensure this does not happen again.”