Aspiring mechanic, 16, died after surgeon pierced his vein using wrong instrument in due to 'great pressures over delays'
Ryan Senior died of multiple organ failure during routine abdominal surgery
Surgeon used wrong instrument that pierced a major vein
Today admitted that had been the case due to time pressures at the hospitalSaid getting the right equipment would have delayed the operation
Doctors administered 31 pints of blood in a bid to stem the bleedingBut the healthy teenager was killed by an embolism and cardiac arrest
13:20 GMT, 10 April 2013
19:18 GMT, 10 April 2013
A teenager died during a routine operation when a surgeon allegedly pierced a major vein after using the wrong instrument, an inquest heard.
Ryan Senior, 16, suffered multiple organ failure during what was supposed to be a ‘low-risk’ 40-minute procedure at Birmingham Children’s Hospital.
An inquest jury was told the Redditch teenager died after a surgeon allegedly used a sharp surgical instrument called a trochar instead of a blunt one, during minor keyhole surgery.
Ryan Senior suffered multiple organ failure during what was supposed to be a 'low-risk' 40-minute procedure at Birmingham Childrens Hospital
A trochar is a medical instrument with a sharply pointed end used to introduce devices such as drains and tubes inside the abdomen.
The jury heard the details of the fateful day from a report read out by Birmingham and Solihull coroner Aidan Cotter.
The report comprised minutes of a meeting between the hospital and Ryan'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.
This occurs when air bubbles block blood flow in a major artery, causing massive blood loss and cardiac arrest, the court heard.
Ryan’s mother Sarah was given the devastating news her only son had died as she waited by his bedside. She was later sent home with his bagged-up clothes and bereavement leaflets.
The teenager had hopes of becoming a mechanic before his death in February 2010
The teenager, who dreamed of being a mechanic, had been suffering from an undisclosed minor health complaint and was otherwise healthy when he went into the hospital on February 16, 2010.
He was due to undergo a laparoscopy, a low-risk procedure that allows a surgeon to access the
inside of the abdomen and pelvis with a tiny camera. Pictures are then flashed back to medics as carbon dioxide gas is pumped into the stomach to increase space.
But a hospital report after Ryan’s death is said to have claimed the operation took a tragic twist when Dr Harish Chandran allegedly used a sharp trochar instead of a blunter implement.
A tear was made in a major vein and gas escaped into the blood stream, resulting in an embolism which led to cardiac arrest and organ failure.
The jury inquest, sitting at Sutton Coldfield Town Hall, was told medics battled for more than two hours to resuscitate Ryan, administering 31 pints of blood in a bid to stem the bleeding.
The operation was led by Dr Chandran, the hospital’s clinical director for surgery, and assisted by Dr Harriet Corbett.
Giving evidence today, Dr Chandran
claimed he performed the surgery with a piece of equipment he was not
comfortable with due to 'great pressure' put on him to to reduce delays
at the hospital.
He also admitted to the hearing that he made the fatal incision, which killed Ryan.
Dr Chandran told the jury: 'Before
the surgery I was informed that the reusable blunt trocar I had
requested was not available but that a disposable plastic blunt trocar
'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 trocar rather than a sharp one.'
Choking back tears, Dr Chandran went on to describe the moment Ryan died on the operating table.
He added: 'I noticed after I had
inserted the trocar that it was not blunt so I removed it and continued
with surgery. On inspection there was no sign of blood so we continued.
'But on inserting the camera I realised not enough CO2 had gone in – so the pressure was increased.
'Almost immediately the patient went into cardiac arrest.
'External cardiac massage was begun and it was suggested a gas embolism may have formed to stop the heart beating.
'On extracting the equipment blood
came out. I packed the area with gauze to stop the bleeding and Dr Tim
Jones, a cardiac specialist was called.'
Dr Chandran told the inquest that Dr
Jones had succeeded in stopping the bleeding using a special treatment
that involved cooling the body to 35 degrees.
But after two hours and 20 minutes of trying to save Ryan he was pronounced dead.
Ryan’s aunt Tracy Hunt had driven him and his mother Sarah to the hospital.
They sensed something was wrong when they were still waiting beside his bed after an hour and 20 minutes.
The tragic death of 16-year old Ryan occurred at Birmingham Children's Hospital
'A man in a suit and a nurse came out
and closed the curtains around the cubicle and told us they had been
fighting to save his life for the last hour,' Mrs Hunt said in a
The sisters were later taken into a
room and given the heartbreaking news that Ryan had died. Tracy said her
devastated sister was handed some leaflets on bereavement along with a
carrier bag with her son’s clothes inside.
She added: 'We loved Ryan dearly and cannot express the pain we have suffered since his death.
'Sarah’s world was turned upside down when he died. He was her only son and her best friend.
'She has left his room untouched since he died and goes in twice a day to say good morning and good night.'
The jury was told a post-mortem examination conducted by Dr Adrian Warfield also revealed an unexplained second small wound, near Ryan’s belly button and where the first incision had been made.
The inquest also heard yesterday from several nurses, including Anna Fitzgerald, who phoned Dr Chandran before the operation to say there was a problem with the equipment.
The camera that he preferred to use was not available, she said. The doctor was later shown three separate boxes of equipment and she said he said he did not mind which one he used.
The one selected for use contained the sharp trochar. When it was pulled from his body, he started bleeding, which was not expected.
The inquest continues.