The family of a heart patient who died after the first robotic heart operation of its kind in the UK said lessons must be learned from the “catalogue of errors” that were made.
Following an inquest into the death of Stephen Pettitt, 69, it emerged that Newcastle Hospitals NHS Foundation Trust dismissed Sukumaran Nair who was lead surgeon at the Freeman Hospital for the procedure which ended in tragedy.
In February 2015, the father-of-three was the first person in the UK to undergo robotic mitral valve surgery, but after a lengthy operation which had to be completed with conventional open heart surgery, he died from multiple organ failure.
His family released a statement saying an investigation revealed “a catalogue of errors including significant deficiencies in training and competence of the surgeon who had performed the procedure, who was subsequently dismissed”.
The inquest in Newcastle heard an expert’s opinion that Mr Pettitt would have stood only a 1-2% chance of dying had conventional, open heart surgery been used to repair or replace his leaking valve.
Mr Nair had no face-to-face training on using the robot before he operated on Mr Pettitt, but had watched similar procedures in the US and Holland and practised alone on a simulator.
Trained experts in using the Da Vinci robot, known as proctors, were in the theatre to help, but left before the complex procedure finished.
It was made more complicated and lengthy by sutures being found to be misaligned and the robot camera being blinded with blood.
It emerged on the last day of the inquest that these proctors, who flew in from outside the UK, could not have stepped in to take over as they were not registered with the General Medical Council.
The inquest heard Mr Nair had long “cross-clamp” times – referring to the period where the heart was deliberately shut off from the blood supply to allow the procedure to take place – in previous operations using “minimally invasive” techniques.
And undertaking a new method of surgery would take longer.
It was found the operating theatre team had not agreed the point after which robotic surgery should be converted to open heart surgery.
Mr Pettitt’s “cross-clamp” time of more than six hours was a cause for concern, the inquest heard.
Earlier, cardiac expert Professor David Anderson told the inquest that although techniques have improved in keeping a “cross-clamped” heart viable, there are still limits.
“When it gets to two or three hours, there is an ever-increasing nervousness that the heart will not function very well,” he told the inquest.
Coroner Karen Dilks gave a narrative conclusion, 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 in the light of the operation.
These include how proctors are recruited and making sure there was clarity over what was expected.
She will also contact the Royal College of Surgeons and the Department of Health asking them to consider whether national guidelines surrounding how new procedures, like the use of robots, should be brought in.
Northumbria Police launched a criminal investigation into what happened and called in Prof 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.
The surgeon, who now works in Scotland, told the inquest he no longer uses robotic techniques.
After the inquest, Dr Andy Welch, medical director for the Newcastle Hospitals Trust, issued a “heartfelt apology” to Mr Pettitt’s widow.
He said: “Unfortunately, on this occasion, we failed to ensure the standard of care that would reasonably be expected of us with a tragic outcome.
“Following Mr Pettitt’s death, the robotic heart programme was stopped immediately and significant changes have been made, following a detailed investigation, in respect of process and training requirements, relating to the introduction of new procedures.”
He said the Trust has already largely addressed the issues raised by the coroner.