Teenage boy died on the operating table after surgeon ‘tore a vein with the wrong instrument’


A teenage boy died on the operating table after a bungling surgeon tore a vein when he used the wrong instrument during a routine operation, an inquest has heard.

Ryan Senior, 16, suffered multiple organ failure during what should have been minor keyhole surgery at Birmingham Children’s Hospital on February 16, 2010.

But he died after the hospital’s clinical director for surgery Harish Chandran used a sharp surgical tool – a trochar – instead of a blunt one which pierced a major vein.

Ryan Senior died after a surgeon pierced a major vein in his abdomen during routine surgery at Birmingham Children's Hospital
Ryan Senior died after a surgeon pierced a major vein in his abdomen during routine surgery at Birmingham Children’s Hospital

An inquest heard Ryan suffered a gas embolism which caused massive blood loss and eventually a fatal cardiac arrest.

Shockingly, a nurse broke the news to Ryan’s mother Sarah and aunt Tracey Hunt because the surgeon was too upset to speak.

She then told them she wasn’t trained in dealing with deaths before handing them a few bereavement leaflets along with a plastic carrier bag containing Ryan’s clothes.

A jury inquest at Sutton Coldfield Town Hall head doctors battled for two hours to save the teenager’s life and pumped 31 pints of blood into him but to no avail.

Mrs Hunt, who had driven Ryan and his mum to the hospital prior to the operation, told the hearing they were told he had died while they waited by his bedside.

She said in a statement: “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.

Birmingham Children's Hospital where the bungled operation took place that killed Ryan
Birmingham Children’s Hospital where the bungled operation took place that killed Ryan

“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.”

Ryan, from Redditch, Worcs., who dreamed of becoming a mechanic, suffered from a minor health complaint but was otherwise fit when he underwent a laparoscopy.

The procedure involves a surgeon accessing the abdomen with a tiny camera which beams pictures back to medics while carbon dioxide gas is pumped into the stomach to increase the space.

A hospital report claimed the routine procedure went tragically wrong when Mr Chandran used a sharp instrument instead of a blunt one to insert the camera near Ryan’s belly button.

But anaesthetist Dr Jason Lewis disputed the official account of what happened in the operating theatre and claimed it was Dr Harriett Corbett who made the fatal incision.

Dr Lewis said: “She (Dr Corbett) made the first incision with the scalpel and then tried to insert the port (piece of equipment).”

Birmingham and Solihull coroner criticised Dr Lewis’s decision to send his assistant home soon after the operation started.

The inquest also heard yesterday from several nurses, including Anna Fitzgerald, who phoned Mr 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 out of Ryan’s body blood came out which should not have happened.

The inquest, which will heard evidence from 22 witness, is expected to last a week.

Giving evidence, Harish 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, from Chennai, India, 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 was.

“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.

The inquest heard how the teenager had undergone surgery in order for doctors to search for his testicles, which were believed to have never descended into his scrotum.

Mr Chandran added: “Ryan’s notes showed that he had never seen his testicles present in his scrotum, but that his hormone levels were normal.

“This meant it was likely they had not descended.

“I gave Ryan and his mother three options, to remove both due to the increased likelihood of malignancy, to remove one and secure the other in the scrotum, or to secure both in the scrotum.

“Ryan and his mother opted for the third option and consent was obtained to operate.”

The inquest continues.


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