Source · Prevention of Future Deaths

Max Haigh

Ref: 2016-0082 Date: 1 Mar 2016 Coroner: Philip Holden Area: West Yorkshire (East) Responses identified: 0 / 1 View PDF

Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.

Date 1 Mar 2016
56-day deadline 26 Apr 2016 est.
Responses identified 0 of 1
Child Death (from 2015) Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.
View full coroner's concerns
In the circumstances it is my statutory duty to report to_you: The being

_ Following surgery the surgeon prepared a note of his operation for the medical records_ It was anticipated that Max may, in the future, require further surgery _ The note of the surgery was unsatisfactory and failed to set out:- (a) position of the ventricular septal defect ("VSD") and how it was enlarged; b) A full description of the VSD; position of the tricuspid valve; techniques that were used by the surgeon himself (2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery.

Report sections

Investigation and inquest
On 24th June 2013 an investigation into the death of Max James Haigh was commenced_ investigation concluded at the end of the Inquest on 5th February 2016. The conclusion of the Inquest was a Narrative Conclusion; the medical cause of death 1(a) Multiorgan failure (due to heart failure), (b) Cardiomegaly with myocardial fibrosis and lymphocytic myocarditis and (2) Previous cardiac surgery for complex congenital cardiac anomaly and pulmonary regurgitation:
Circumstances of the death
Max Haigh was born 11th April 2012. He had a complicated cardiac defect; including a double outlet right ventricular septal defect; pulmonary stenosis and a left sided superior vena cava to the left atrium On 18" March 2013 he underwent surgery and an unsuccessful attempt was made to perform a double ventricular repair. (In the event a pulmonary band was fitted). The surgery was performed competently. He was discharged from hospital on the 11lh April 2013 and his subsequent recovery was unremarkable before he presented to hospital on the gth June 2013 with a history of vomiting and being unwell He remained in hospital until the 12th June 2013 when his condition deteriorated _ Attempts at resuscitation were unsuccessful and death was pronounced at 2310 hours on 12th June 2013. At post mortem significant findings were that he had multiple organ failure; an enlarged heart (cardiomegaly) , myocardial fibrosis and lymphocytic myocarditis_
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.

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Report details

Reference
2016-0082
Date of report
1 March 2016
Coroner
Philip Holden
Coroner area
West Yorkshire (East)

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 26 Apr 2016 (estimated).

Sent to

St James’s University Hospital

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