Eastbourne DGH has apologised to the family of a 35-year-old mother who died after a surgeon cut the wrong blood vessels to remove a potentially cancerous tumour which turned out to be benign.
Nicole Haynes, of Sunset Close in Pevensey Bay, died on March 29, 2012 at Kings College Hospital after keyhole surgery at the DGH on March 27 to remove a tumour from her adrenal gland.
An inquest into her death was held by Coroner Alan Craze at Eastbourne Town Hall on Thursday (November 26)
Mr Craze was told Mrs Haynes had suffered from breast cancer in 2011 and it was felt it was best to removed the lump on the glands near her kidneys in case it was malignant.
Mrs Haynes was admitted for the operation in March and the surgery was carried out by Steve Garnett, urological surgeon at Eastbourne DGH.
Mr Garnett gave evidence at the inquest and told Mr Craze he had carried out this particular operation twice on his own bur had been involved with 17 other procedures.
Mr Craze asked about the statistics and risks involved in the operation.
Mr Garnett said, “Mortality rates are very low from this and some of the figures have suggested 0.5 per cent but I would think it was lower than that.”
He explained complications were ‘rare’.
However, Mr Garnett made a catastrophic mistake and cut and clamped the blood vessels to the gut instead of those to the adrenal gland.
This fatal error was not discovered by staff straightaway, until Mrs Haynes’ condition started to worsen and the level of acid in her body increased to a fatal level, known as acidosis. Naomi Forder, the anaesthetist who was monitoring Mrs Haynes throughout the procedure, said she had mentioned an increased heart rate to Mr Garnett during the operation but had decided the acidosis was down to dehydration because it was only ‘slightly raised’. Fluid was given to try and bring the level down.
Mr Garnett, who was assisted by urologist Mr Bourghli throughout the operation, said, “This is something I have thought long and hard about and I felt the operation went well at the time.
He explained he carried out the surgery via a monitor and said, “I thought that I was in the right place and I thought that what I was seeing made sense to me.
“In retrospect, I obviously was disorientated but I didn’t think so at the time.”
He explained to Mr Craze, “What actually happened was that I misidentified the blood vessels to the adrenal gland. I clamped the wrong blood vessels. I clamped the vessels that supply the gut and the liver.”
Mr Garnett was alerted to her worsening condition later that day and at Thursday’s inquest he described her as ‘extremely unwell’. The CT scanner at Eastbourne DGH was broken on March 27 and so Mrs Haynes had to be taken to the Conquest Hospital in Hastings for a scan. By this time, due to her worsening condition, she was becoming confused.
She was then taken back to Eastbourne DGH where a decision was made to send her, in a blue lighted ambulance, to Kings College Hospital in London. She arrived at 9am and was in theatre for emergency surgery with consultant liver specialist, Professor Nigel Heaton, at Kings College, by 10am on March 28.
He said the clamping of the blood vessels was a ‘clear error’ and explained it had been done in a ‘highly competant manner’.
Mr Heaton was asked whether earlier intervention by him and his team could have saved Mrs Haynes. He explained that even if he had of seen her the day before she would most likely have died.
Mr Craze recorded a verdict of surgical accident.
Speaking after the inquest, the family’s solicitor, Amy Fielding of Stewarts Law, said, “It is rare to come across such a tragic catalogue of events as those suffered by Mrs Haynes and her family in March 2012. Fortunately following the conclusion of the inquest and the claim admitted by the hospital, the family are now able to move on and remember Nicole as a loving wife, mother, daughter, sister and friend. She was well known locally and gave so much to everyone she met; she still had so much more to give.
“The fundamental errors made by the hospital in this case have irrevocably damaged the lives of Mrs Haynes’ family and friends. As a family they only hope that new hospital procedures have been implemented and systems changed so that situations like this never happen again.”
Mrs Haynes is survived by her husband, Nigel, and their young son.
Dr David Hughes, medical director, said, “We would again express our sincere condolences to the family and friends of Nicole Haynes.
“As the inquest has heard Nicole died following laparoscopic surgery on March 27, 2012. The Trust deeply regrets the circumstances that led to her death and for that we would unreservedly apologise.
“Two investigations were undertaken with the aim of lessons being learned from this tragic incident and as a result, as the Coroner recognised, we have made a number of significant and robust changes to prevent a similar event occurring again.
“No words offered now to the family can comfort them from the pain of losing a much loved wife and mother. On behalf of the Trust and the staff involved in her care all we can say is sorry.”