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.
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.
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.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS