PERFUSION REPORTS

REPORT
131
DATE
23/10/2024
TITLE
Human Factors
DETAILS OF INCIDENT

Patient underwent aortic root, ascending aorta, aorticvalve replacement and CABG. Following the initial bypass the patient remained in theatre for assessment of bleeding. Decision made to re-open the chest and requirement for further cardiopulmonary bypass required in an emergent fashion to resolve bleeding. This was now out of hours with the 1st on call being occupied by a concurrent emergency leaving only the 2nd on call to respond. A circuit with an emergency checklist and full pre-bypass checklist was utilised. Heparin was added to the bypass prime once 'off and clamped' and circulated through the main re-circulation line (arterial to venous bridge). The bridge was not re-clamped and bypass initiated. Low blood pressure and low patient NIRS were recorded for a significant period of time. Roller pump flows (no flow probe post bridge) were increased beyond calculated full flow and troubleshooting commenced. The unclamped bridge was identified and full flow to the patient re instituted.

DETAILS OF INJURY TO PATIENT

INVESTIGATION and INQUEST On 23 September 2024

I commenced an investigation into the death of Colin Charles BROOKS.The investigation concluded at the end of the inquest on 29th May 2025. The conclusion of the inquest was that;The deceased died as a result of a hypoxic ischaemic brain injury after blood flow to his brain was compromised during emergency cardiac surgery when there was a delay in the reapplication of abridge clamp to the circuit of a cardiopulmonary bypass machine.

TYPE OF DEVICE/MANUFACTURER
ACTION TAKEN

Safety checks have been amended to include the specific clamping of the A-V Bridge andnot just ‘recirculation lines’. The department will continue to implement a2-person pre bypass checklist and maintain a 2-person emergency checklist for every procedure. Arterial flow probe is placed post A-V bridge unless SACP isbeing utilised and circulation through the bridge required.

RESPONSE FROM MANUFACTURER
ADDTIONAL INFORMATION

REGULATION 28 REPORT TO PREVENT FUTURE DEATHS

SUPPORTING VISUALS/VIDEO
SUPPORTING DOCUMENT

OTHER PERFUSION
 REPORTS

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REPORT NO
133
7/7/25
Disposables: Oxygenator Failure
REPORT NO
132
11/6/25
Hardware: Maquet cardiosave hybrid
REPORT NO
131
23/10/24
Human Factors
REPORT NO
130
19/5/25
Hardware: Level Alarm
REPORT NO
129
3/5/25
Human Factors
REPORT NO
128
25/5/25
Single Station Selectatec Type Backbar for Vapouriser. 9000-001
REPORT NO
127
4/1/25
Eurosets Oxygenator leak
REPORT NO
126
1/3/25
Oxygenator Failure
REPORT NO
125
11/2/25
Hardware Error: Bubble Detector
REPORT NO
124
1/10/24
HCU/ Hardware incident/ Human Factors
REPORT NO
123
5/7/24
LivaNova S5 Roller Pump Fault
REPORT NO
122
5/4/24
Oxygenator Failure
REPORT NO
121
8/3/24
Disposables: Eurosets Adult ECMO Oxygenator
REPORT NO
120
1/5/24
Oxygenator Failure
REPORT NO
119
Hardware: HCU Contamination
REPORT NO
118
12/9/23
Human Factors: ECMO Mobilisation
REPORT NO
117
27/9/23
Disposables: Oxygenator failure
REPORT NO
116
14/9/23
Disposable Issue: Reservoir in CPB circuit
REPORT NO
115
13/9/23
Disposable Error/ Eurosets New Born ECMO oxygenator (EU5056) leak
REPORT NO
114
13/7/23
Dispoables: Bonding Solution on Tubing
REPORT NO
113
21/3/23
ERC Failure
REPORT NO
112
20/2/23
HLM Hardware Error: S5 HLM - Dual roller cardioplegia
REPORT NO
111
10/2/23
Human Factors/ Gas leak
REPORT NO
110
31/1/23
DISPOSABLE FAULT
REPORT NO
109
19/1/23
Disposable issue
REPORT NO
108
3/1/23
Disposable issue: Oxygenator leak
REPORT NO
107
6/12/22
Hardware fault. Electronic gas Blender failure
REPORT NO
106
1/11/22
ECG Interference
REPORT NO
105
9/9/22
Issue with use of disposable
REPORT NO
104
13/6/22
Human Factors
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