Robot knocks assisting medic's hand during routine heart surgery leading to tragic death of 69-year-old patient
Stephen Pettitt tragically died after a visit to Newcastle's Freeman Hospital in February 2015 for a heart valve repair surgery that went catastrophically wrong
A groundbreaking heart surgery that was being assisted by a robotic surgeon went catastrophically wrong after it "spiraled out of control" and resulted in the death of a father-of-three, an inquest has heard.
Sixty nine-year-old retired music teacher and conductor Stephen Pettitt went under the knife at Newcastle's Freeman Hospital in February 2015 for a seemingly routine heart valve repair, but would tragically die after a series of mishaps and mistakes.
The Daily Mail reported the developments in the inquiry, which laid bare how underprepared the surgeons were as they undertook the operation. Lead surgeon Sukumaran Nair confessed he was "running before he could walk" in using the robot, christened Da Vinci, as he had not even used it in a training capacity. He is also said to have missed a training session in Paris that taught surgeons to use the robot on a cadaver, as well as another such session at his hospital because he was busy with surgery.
Nair and consultant cardiothoracic assisting surgeon Thasee Pillay were faced with a host of problems as the surgery went underway, including the absence of proctors — supervisory experts trained to take over to avert potential crises — problems in communication due to poor audio quality, and mistakes in suturing Pettitt's heart.
The inquest heard of how the proctors had gone home part of the way through the procedure when Nair was confronted with poor visibility through the robot's camera after Pettitt's intra aortic septum was damaged. Their absence would prove to be a turning point.
Dr. Anthony George, a consultant anesthetist in the operation, testified that Nair was aware the proctors planned to leave at lunchtime but that he chose to go ahead with the surgery anyway. He said that the "communication problems the two surgeons experienced was a core part of the failure," adding that their departure was "significant." Consultant cardiothoracic anesthetist Kevin Brennan echoed that sentiment, describing their departure as a "crucial moment" and that the loss of their "vital assistance was a major blow to critical time."
The poor communication also meant that Pettitt's sutures were done poorly, and that would ultimately prove fatal. Pillay told the hearing that he was standing just a few feet away from Nair and was facing the patient while the lead surgeon had his head in a console and was facing away from him,
He stated he could hear Nair through a microphone but that he had to shout to make himself heard because the voice was "tinny" and "acoustics were not very good." When asked if communication was difficult, he answered, "There were times when I raised my voice, one was when the sutures were not being placed in an organized fashion and were criss-crossed."
The stitches had to thus be taken out and replaced, extending the operating time further. Pillay said he had to raise his voice again when a colleague standing over Pettitt "had his arms knocked by the robot," and that he called for the assistance of the proctors only to realize they had already left. He said he assumed they had "gone to the coffee shop for a break."
George told the inquest he felt the outcome would have been different if the surgeons had been able to place the sutures precisely and correctly. He also said he tried to tell the surgeons he was concerned the operation was going badly but that he backed off because "it was not my place to harass surgeons and that is not the role I took on."
The robotic surgery was abandoned part-way through, but it would already prove too late. At that point, Pettit's heart was functioning "very poorly," and he would go into multiple organ failure a few days later and die.
Nair said he had made it clear to the 69-year-old that he would be "the first robotic mitral valve patient" and that he had explained the risks, but confessed he had not informed Pettitt he ran a higher risk because he was the first robotic mitral valve patient.
The surgeon now works in Scotland and no longer performs robotic surgery.