Boy, 4, went into hospital to have his tonsils out and died after 15,000-to-one complication, drowning in his own blood
Oakley Gould died after he suffered cardio-respiratory failure when his lungs filled up after a 'catastrophic bleed' from a tiny artery
07:29 GMT, 12 June 2012
A four-year-old boy who went into hospital to have his tonsils out died after drowning in his own blood as a result of a 15,000-to-one complication, an inquest heard.
Oakley Gould seemed to be recovering well after the routine operation at his local hospital in Stevenage, Hertfordshire, and was sent home.
But six days after the surgery, he began losing large amounts of blood during breakfast and his terrified parents paramedics Hayley Clark and David Gould called an ambulance.
Doctors at the same hospital were unable to save Oakley, who had suffered cardio-respiratory failure when his lungs filled up after a 'catastrophic bleed' from a tiny artery.
Procedure: Oakley Gould had seemed to be recovering well after the routine operation at Lister Hospital in Stevenage
The inquest heard that Oakley had been back to hospital with a temperature and with low blood oxygen levels but was discharged again, with no indication of what was to come.
Coroner Edward Thomas told his grieving mother and father: 'I have heard what happened that day.
'Oakley left hospital. He seemed OK and suddenly, during breakfast, he had this catastrophic bleed.
'What happened then will always be with you. I feel so sorry for you because it must have been absolutely awful.'
Clinicians had recommended surgery for the youngster because he suffered from obstructive sleep apnoea, where his pronounced adenoids and tonsils made it hard for him to breathe, especially at night.
Dr Petros Vlastarakos said the operation on the boy's tonsils was one of three similar ones on the day, and that he had carried out 142 of the procedures in the UK and about 40 more in his native Greece.
He used a bipolar diathermy, which uses a low electrical current to heat a concentrated area of tissue to cauterise arteries and veins to stop bleeding.
He also tried to attach ties as an added measure but could only manage it on one of them, despite trying twice on the second one. His senior consultant colleague also tried but could not fit the tie.
'I couldn’t get a grip on the tissue,' he said, yet he added that he believed he was the only surgeon in his department who used both diathermy and ties, as his colleagues were satisfied with just diathermy.
He explained how, following the operation at the Lister Hospital, the usual checks were conducted and Oakley was not bleeding.
Tragedy: The post-mortem examination on Oakley was carried out at Great Ormond Street Hospital
Marian Malone, who carried out the autopsy at Great Ormond Street Hospital, told the coroner: 'At post mortem examination there was actually very little to see with the naked eye. It seemed to have healed as well as expected.
'I also examined to see if any damage had been done to the major arteries supplying that area and they were all intact.'
She said it was only when she examined samples under a microscope that she found an artery with necrosis, or dying tissue, in its wall.
In the absence of any infection, she suggested a possible cause of the so-called secondary haemorrhage could have been part of the healing process itself.
'Granulation tissue is healing tissue and it has lots of blood vessels growing in it because it is the new tissue growing in to repair. It is very vascular,' she said.
'The granulated tissue is all healing and you have the broken surface on top. The tissue is gradually replaced but just at the stage when the damaged tissue is coming off it is possible to have secondary haemorrhage.
'The next area is very rich in vessels and is exposed to the surface. It is typical of how catastrophic haemorrhage happens.'
Explaining that the condition was 'recognised, albeit rare', she warned: 'There are many publications demonstrating that it can even happen in hospital, that patients can die because of the rapidity.'
Dr Vlastarakos added that the only way Oakley would have stood a chance of survival were if he and an anaesthetist had been standing by him with their equipment when the haemorrhage occurred.
Mr Thomas recorded a narrative verdict on Oakley at the inquest in Hatfield, adding: 'I will record that Oakley died from a recognised late complication from an operative procedure.'
He told the parents: 'One of the sad things is that what happened here is extremely rare but not rare to the people who suffer from it, because it happened to you.'