“Hierarchical culture” existed in theatres at Hinchingbrooke Hospital, according to report
PUBLISHED: 17:30 19 October 2017
A “hierarchical culture” existed in the operating theatres at Hinchingbrooke Hospital, an inquest into the death of Somersham man Peter Saint has heard.
Mr Saint, aged 71, died on June 28, 2016, five days after he suffered a cardiac arrest during routine knee surgery.
He was left with irreversible brain damage after he was deprived of oxygen for more than 20 minutes when a breathing tube was wrongly inserted into his oesophagus.
A report into the incident was commissioned by the hospital’s management team and an action plan was developed. The report’s author recommended human factors training, workshops and new guidelines for obese patients as well as advice for dealing with difficult airways.
It also commented on the culture in the theatres and advised that all members of the team “must have a voice”.
Dr Kneeshaw, who carried out the report, was critical of the incident, which led to Mr Saint’s death, describing it as an “unacceptable error” which was compounded by a “failure to listen to non-medical staff”.
The inquest heard that two other senior consultant anaesthetists failed to correctly diagnose the misplaced tube, and this was likely to have “emboldened Dr Hille to stick to his view”, and even when the error was pointed out by a less senior colleague, they did not act, wasting more time for Mr Saint.
Operating theatre technician, Mick Collins came into the theatre when there were three senior consultant anaesthetists working on Mr Saint and correctly identified the problem, but his view was rejected.
The hearing, taking place at Huntingdon Town Hall, was told that the hospital’s clinical director for theatres and critical care, Dr Anthony Brooks, was informed there had been an incident at about 5pm on June 23.
Giving evidence on the fourth day of the inquest, he was asked by assistant coroner Sean Horstead: “Was insufficient attention paid to Mr Collins, given his experience?”
Dr Brooks replied: “With hindsight, yes, of course, that seems obvious.”
Later he said he couldn’t explain how the error could have occurred as it had always been his view that if there was any doubt about the placement of breathing tubes they should be removed. He also said the lack of CO2 should have been obvious from a flat white line and a zero reading on the monitor.
“I can’t explain how things turned out the way they did,” said Dr Brooks.
“There doesn’t seem to be any explanation for the error.”
It was on Dr Brook’s instructions that the theatre monitor used by Dr Hille was removed from the theatre immediately to ensure the data on the machine was preserved. He also asked technical support services at the hospital to reconfigure the machines so the display no longer showed the two white lines, denoting O2 and CO2, which could have led to confusion on Dr Hille’s part.
After giving his evidence, Dr Brooks offered an apology to Mr Saint’s family.
“I am very sorry this happened to your brother while he was in the care of the trust,” he said.
The inquest continues.