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Zack Hider inquest: Surgery 'overdose' caused baby's death | |
(35 minutes later) | |
A 19-day-old boy died after being given four times the solution needed to stop his heart during surgery, a coroner has ruled. | A 19-day-old boy died after being given four times the solution needed to stop his heart during surgery, a coroner has ruled. |
Zack Hider, from Portsmouth, was born with a congenital heart defect. | |
A "mistake" was made during the heart operation at Southampton General Hospital on 11 November last year, the inquest in Winchester was told. | A "mistake" was made during the heart operation at Southampton General Hospital on 11 November last year, the inquest in Winchester was told. |
Zack's parents said they did not blame any individual but hoped lessons were learned to prevent similar mistakes. | |
'Bruised' heart | 'Bruised' heart |
Recording a narrative verdict, coroner Graham Short said pressure from the excess dose of the heart-stopping solution had been the primary cause of death. | Recording a narrative verdict, coroner Graham Short said pressure from the excess dose of the heart-stopping solution had been the primary cause of death. |
Moments after the mixture of blood and chemicals was injected, Zack's heart turned "stiff" and looked "bruised", surgeon Michael Kaarme told the inquest. | |
"I didn't know what was happening," he said, adding, "I didn't have any experience like this." | "I didn't know what was happening," he said, adding, "I didn't have any experience like this." |
The man operating the machinery that controlled the solution, perfusionist Richard Hartshorne, did not appear in court. | The man operating the machinery that controlled the solution, perfusionist Richard Hartshorne, did not appear in court. |
In a statement, he said it had not been made clear a procedure requiring the heart to be stopped was being carried out, until part way through the operation. | In a statement, he said it had not been made clear a procedure requiring the heart to be stopped was being carried out, until part way through the operation. |
An inquiry found Zack had been given a dose of the solution for a much larger child, like the previous patient in the theatre. | |
Mr Short said: "The volume was not adjusted prior to delivery for reasons that I've not been able to fully establish." | Mr Short said: "The volume was not adjusted prior to delivery for reasons that I've not been able to fully establish." |
He said even when the operation was abandoned, Zack's heart could not be started and he died in hospital nine days later. | |
"By that time, the damage had been done," he said. | "By that time, the damage had been done," he said. |
'Severe reaction' | |
In a statement, Zack's parents, Gary and Sarah Hider, said they "did not blame any individual but only hope lessons are learned to make sure similar mistakes are not made in future." | |
Neil Pearce, associate medical director for patient safety at University Hospital Southampton NHS Foundation Trust, said: "We accept full responsibility for the incident and have apologised unreservedly for it. | |
"The error made was very rare and led to a severe reaction in Zack's heart muscle which took away his chance of surviving the complex surgery he was due to undergo." | |
He said an "immediate investigation" had led to the introduction of a number of "important new safety measures" which he added had subsequently been shared with all paediatric cardiac centres in the UK "to try to eliminate the risk of a similar incident occurring again". |
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