A
baby boy died after an untrained doctor pressed the wrong button on his
bypass machine because it was a less "horrid" colour than the other, an
inquest heard yesterday. Four-month-old Thomas
Smith was on a heart and lung bypass machine when Simon McGuirk, a
cardiac surgical registrar, accidentally turned it off. Mr
McGuirk said that he did not know whether to press the orange or blue
buttons to restart the machine, so opted for the blue. It sent the
machine into reverse, sucking blood from Thomas's body. He died a short
time later. The
inquest heard that Thomas had been admitted to Birmingham Children's
Hospital for an operation to cure two holes in his heart. The
operation was a success but a ventilator he was on stopped working, he
suffered a heart attack and was switched to the bypass machine. Mr
McGuirk told Birmingham coroner's court that he was cleaning up some
blood that he had spilt on the machine when he accidentally lifted the
lid and it stopped working. He said that he had
been holding a metal line clamp at the time and that this may have
interfered with a magnetic clasp keeping the lid shut. "I don't know
how or why [it happened]," he said. "It was thought it might have been the metal clamp causing the loss of magnetism or me lifting it without my knowing." He
said that Thomas's blood pressure had dropped the moment that the
machine stopped and that, as soon as this happened, he called for help.
Once resuscitation measures were in place, Mr
McGuirk said that a nurse had telephoned a member of staff who knew how
to restart the machine and relayed instructions to him. Mr
McGuirk said that there were two sets of coloured buttons on the
machine, one blue, one orange. "I was indicated to press two buttons at
the same time to restart the machine," he said. "She
didn't know which colour they were. In view of that I went for two blue
which I thought was a less horrid colour than the orange." Mr
McGuirk said that this had sucked blood from Thomas instead of sending
it to him and that he had immediately switched the machine off. "I should have pressed the two orange buttons, which would have pushed the blood from the circuit to Thomas," he said. "In deciding which set of buttons I was meant to press I took a stab in the dark. It was a 50-50 chance." Mr
McGuirk said that it had been an error on his part for which he took
full responsibility but that Thomas had not suffered any damage as a
result. The baby's mother, Lisa Weale, 35, from
Longbridge, Birmingham, said that after the bypass incident she was
told that the duty doctor was not qualified to monitor the machine. She
was further told that the hospital did not have the resources to ensure
there was always somebody on duty who was. "[The doctor] was unaware how to use the machinery, as were most of the team," she said. The inquest continues. |