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
103
25/7/22
Human Factors
REPORT NO
102
7/7/22
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REPORT NO
101
6/4/21
Irregular blood flow/foreign looking substance in Oxygenator
REPORT NO
100
20/4/22
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REPORT NO
099
20/4/22
Human Factors: BiVAD Error
REPORT NO
098
4/4/22
REPORT NO
097
19/3/22
Disposables Issue
REPORT NO
096
18/3/22
Bubbles Sensor Activation
REPORT NO
095
1/1/22
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REPORT NO
094
1/11/21
Oxygenation failure upon commencement of CPB
REPORT NO
093
1/11/21
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REPORT NO
092
1/10/21
Vapourizer Issue
REPORT NO
091
1/10/21
Oyxgenator Leak
REPORT NO
090
1/10/21
Breach of chemical cleaner
REPORT NO
089
1/9/21
Sechrist Gas Blender Sweep on ECMO
REPORT NO
088
1/9/21
Oxygenator High Pressure Events
REPORT NO
087
1/10/21
Leaking one way valve
REPORT NO
086
1/7/21
Electronic Gas Blender Fault
REPORT NO
085
1/2/21
Protamine Administration Issue
REPORT NO
084
1/6/21
Damaged roller pump lid
REPORT NO
083
1/6/21
IABP malfunction
REPORT NO
082
1/1/21
Accidental cardioplegia administration
REPORT NO
081
1/4/21
S5 Double Roller Pump incident
REPORT NO
080
1/5/21
Human factors issue
REPORT NO
079
1/6/21
Centrimag battery module failure
REPORT NO
078
1/6/21
Sampling manifold valve fault
REPORT NO
077
1/5/21
IABP transport issue
REPORT NO
076
1/4/21
Modified Ultrafiltration (MUF) Issue
REPORT NO
075
1/3/21
Electromagnetic interference with HLM
REPORT NO
074
1/2/21
HCU40 Failure
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