Robotic surgery death sparks call for UK guidelines
A CORONER will write to the Department of Health and the Royal College of Surgeons after the first patient to undergo a robotic heart surgery of its kind in the UK died when the operation went badly wrong.
Stephen Pettitt, 69, suffered multiple organ failure following the operation by lead surgeon Sukumaran Nair at the Freeman Hospital, Newcastle, in February 2015.
Newcastle Coroner Karen Dilks returned a narrative verdict, saying: “Mr Pettitt died due to complications of an operation to treat mitral valve disease and, in part, because the operation was undertaken with robotic assistance.”
She will write to Newcastle Hospitals NHS Foundation Trust with a series of recommendations about how its policies could be improved. She will also contact the Royal College of Surgeons and the Department of Health to ask them to consider producing national guidelines on the new procedures.
An inquest in Newcastle has heard that surgeon Mr Nair led the operation to repair a leaking mitral valve, after which the dad-of-three Mr Pettitt, from Whitley Bay, North Tyneside, suffered multiple organ failure.
Expert medics – known as proctors – who were supposed to help if things went wrong were unable to assist because they were registered abroad and were not formally registered with the General Medical Council, the inquest was told.
Northumbria Police launched a criminal investigation into what happened and called in Prof David Anderson, an expert in conventional cardiac surgery, to produce a report.
Mr Nair was interviewed under caution
and no criminal charges followed the police inquiry.
Prof Anderson told the hearing that a conventional mitral valve repair operation in Mr Pettitt’s case would have been low-risk.
He said that he found no evidence that the surgical team set a time limit for the robotic surgery after which they should switch to open heart surgery.
He told the hearing: “I would expect there is a plan B to convert.”
He cited expert opinion published in 2016 which suggested a period of two hours of robotic surgery before switching.
“You can lose track of time. I think it is a major deficiency that there was no back-up plan,” he said.
The inquest was told that Mr Pettitt’s heart was “cross-clamped” for six hours and 12 minutes.
Prof Anderson said: “When it gets to two or three hours, there is an everincreasing nervousness that the heart will not function very well.”
Mr Nair carried out the operation from a robotic console assisted by experienced surgeon Thasee Pillay, who was beside the patient.
Near the expected conclusion of the long operation, it was discovered that sutures inside the heart had crisscrossed and needed to be repaired.
By this time the robot camera was blinded by leaking blood.