Baby died after injection error

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A six-week-old boy died after air was mistakenly injected into his bloodstream during a routine operation, a Swansea inquest has heard.

Aaron Havard died in April 2002 at the city's Singleton Hospital.

The inquest jury returned a narrative verdict concluding equipment to prevent the error was available, but was not used, and is not widely used now.

Afterwards, Swansea NHS Trust said it "wholeheartedly supports" work to ensure the mistake cannot happen again.

The inquest in Swansea was earlier warned that "deaths will continue" unless changes were made in some medical equipment.

Aaron died after the stomach operation in April 2002.

Cardiac arrest

Consultant anaesthetist Robert Falconer, who made the error, was cleared by a crown court jury of manslaughter through gross negligence in 2004.

He told the inquest the moment he realised he had injected air into the tube in Aaron's hand he was "absolutely devastated".

At the end of the surgery Dr Falconer was asked to inject air through Aaron's nasal tube into his stomach to check if the procedure had been a success, but he pumped the air into the wrong tube.

The baby suffered a cardiac arrest.

Dr Falconer described to the inquest how he had to tell Aaron's parents what had happened and he said he had told them that he was very, very sorry.

Aaron's parents Kathryn and Philip Havard outside the hearing

Tom Clutton-Brock, an expert in the safety of medical devices, told the inquest in his opinion Aaron had died from human error and poor equipment design.

He also said that in his opinion deaths would continue until changes were made worldwide to the design of syringes and of medical tubes to prevent any future misconnections happening.

The medical director of Swansea NHS Trust, John Calvert, said changes had been made since Aaron's death.

He said it had taken every reasonable step to ensure that lessons had been learned and that recommendations from the National Patient Safety Agency could be in place by September next year.

After the inquest, Swansea NHS Trust issued a statement expressing deep regret and sadness and apologising to Aaron's parents Philip and Kathryn Havard for the "tragic mistake" leading to his death,

It said a thorough investigation after the death had concluded that this was "a dreadful, one-off accident which occurred in spite of the appropriate equipment, procedures and personnel being in place".

The trust said it had taken a pro-active role in drawing the attention of the relevant authorities to the fact that "elements of this equipment can easily be misconnected, with potentially fatal consequences".

The statement also said the trust had been reassured that this issue was being thoroughly investigated by the National Patient Safety Agency whose recommendations are to be published next year.