Family call for improvements after retired farmer dies during a routine operation at Hinchingbrooke Hospital
PUBLISHED: 10:45 25 October 2017 | UPDATED: 11:20 25 October 2017
Hinchingbrooke Hospital says it is addressing staffing issues after a retired farmer was deprived of oxygen for 21 minutes during a routine knee replacement surgery and later died.
The family of the 71 year old, who suffered irreversible brain damage when he was deprived of oxygen, have called for improvements in what they describe as a “dysfunctional and hierarchical anaesthetic department” at the hospital.
Peter Saint went into cardiac arrest during routine surgery last year after a breathing tube was wrongly inserted into his oesophagus instead of the trachea and he went without oxygen for 21 minutes.
He died five days later in the critical care unit.
A five-day inquest at Huntingdon heard that three senior anaesthetists failed to recognise the error.
Tom Harrison, acting for Mr Saint’s family, said: “We are content that this inquest has fully investigated the very unfortunate circumstances that led to the death of Peter Saint. His death was unnecessary and avoidable.
“Nothing we can say or do will bring Peter back, however, we hope the necessary lessons have been learnt by the medical staff and management at Hinchingbrooke Hospital and that appropriate steps have, or will be, put in place to improve, what in June last year, was a dysfunctional and hierarchical anaesthetic department.”
The anaesthetist in charge that day was Dr Ingo Hille who admitted he made a “crucial error” in his misplacement of the tube.
The inquest heard his mistake was compounded by a failure on the part of Dr Abdu Ayman and Dr Vaithseewaran Silva to identify the error.
According to coroner Sean Horstead, this “emboldened Dr Hille” to stick with his view that other factors were responsible for Mr Saint’s decline.
Hinchingbrooke Hospital described the death of Mr Saint, of Somersham, as “unexpected and avoidable” and said it had commissioned an independent report to look into the circumstances of the incident.
It says it is addressing staffing issues
An inquest in Huntingdon heard that the theatre department at Hinchingbrooke was “hierarchical” and questions were raised about whether non-medical and less senior staff, were listened to or “had a voice”.
Dr Kanchan Rege, medical director at North West Anglia NHS Foundation Trust, which oversees the running of Hinchingbrooke Hospital, said: “Following Mr Saint’s death, a report from an independent anaesthetist was obtained and formed the basis of an extensive action plan, on which good progress has already been made.
“A general training programme across our medical workforce has addressed some of the staffing issues raised in the report and some individual retraining has also taken place.”
The anaesthetist in charge that day was Dr Ingo Hille who admitted he made a “crucial error”, in his misplacement of the tube, but the inquest heard this was compounded by a failure on the part of fellow anaesthetists, Dr Abdu Ayman and Dr Vaithseewaran Silva, to identify the error.
Coroner Sean Horstead said Mr Saint’s death had been caused by “human factors” and the hierarchical culture in the theatre had played a significant role in the error not being spotted sooner.