A surgeon has changed his working practices and given himself ‘a wider margin of error’ after the death of a cancer patient.
Stephen Barden died in Sunderland Royal Hospital in February last year - three days short of his 44th birthday - after surgery to remove his tonsils and lymph glands as part of treatment for a tumour on his neck.
An inquest at Sunderland Civic Centre heard examinations had been carried out after the operation to ensure there was no bleeding.
But Mr Barden, of North View Lodge care home, Castletown, had become extremely agitated when waking up and had started to bleed from the right side of his head.
He had been taken back into surgery, but there was no trace of where the blood was coming from.
He had again become agitated on waking and started to bleed from the left side of his head.
I am pleased to hear that procedures have been changed and I hope this unfortunate series of events will be shared by Mr Neugent with his colleagues as a learning experience.Karin Welsh
Mr Barden had been prepared for surgery again but suffered a cardiac arrest in the anaesthesia room and died.
The inquest heard surgeons had used an implement called a harmonic scalpel to cut through veins in his neck. The instrument, which sealed the wounds automatically, was recommended only for use on blood vessels of 5mm diameter or less.
Surgeon Mr Michael Neugent told the hearing he had extensive training and experience with the harmonic scalpel, and had been happy the veins he cut were within the recommended 5mm size - though he had not measured them.
He had changed his working practices since Stephen’s death and only used the harmonic scalpel on smaller veins: “I think it is a very good piece of equipment and I will continue to use it. I have just given myself a much bigger margin of error.
“I now don’t use it on more than 2-3mm. I am much more cautious - but I had used this in this way before and it had not been a problem.
Colleagues were doing the same: “We are all in agreement about how we should keep using the harmonic scalpel,” he said.
“Other surgeons have similar practices now.”
Dr Robert McCormick, who assisted in the operation, also said he had no qualms about using the harmonic scalpel.
Prof James McCall, of Glasgow Queen Elizabeth Hospital, told the hearing he had calculated the maximum possible size of the vein operated on as 6.4mm, though this was the outside limit and it could well have been smaller than 5mm when examined by Mr Neugent.
Deputy coroner Karin Welsh said it was impossible to say whether the veins which were cut had been bigger than recommended: “What I can say to the necessary standard is that, in retrospect, it would have been prudent to use additional measures, such as clips or some type of suture material.
“Whether the use of additional materials would have prevented Stephen’s death, I do not know, But Stephen’s family would have had the benefit of knowing that all that could have been done was done.
“I am pleased to hear that procedures have been changed and I hope this unfortunate series of events will be shared by Mr Neugent with his colleagues as a learning experience.”
She recorded a narrative verdict that Stephen died as a result of haemorrhage following a necessary surgical procedure.
Speaking after the hearing, Stephen’s cousin Kelly Chambers said he had lived in the care home since suffering mild brain damage as a result of a diabetic coma.
The family did not hold anyone responsible for his death: “The hospital did everything they could for him,” she said.
“I always knew the outcome was going to be something like this. I don’t want to spend the rest of my life putting the blame on people.”