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

London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Select and scroll to view chosen report
REPORT NO
043
1/7/19
Getinge Mal-Position Of IABP Catheter
REPORT NO
042
1/2/19
Avalon Dual Lumen Cannula Crack
REPORT NO
041
1/2/19
Custodial Rubber Fragmentation In Spiked Bag
REPORT NO
040
1/10/18
Reservoir Clot
REPORT NO
039
1/10/18
Pall Clot In Cardioplegia Circuit
REPORT NO
038
1/10/18
Maquet HL20 Cardioplegia Pump Error
REPORT NO
037
1/10/17
Temed D200 Haemoconcentrator Clot
REPORT NO
036
1/10/17
Oxygenator issue
REPORT NO
035
1/10/17
Medtronic Fusion Oxygenator Blood To Gas Leak
REPORT NO
034
Possible Medtronic Fusion Oxygenator Failure
REPORT NO
033
Fannin Heparin Ampules Shattering
REPORT NO
032
Sucker Placed In Raceway In Wrong Direction
REPORT NO
031
High Transmembrane Pressure Gradients
REPORT NO
030
Faulty Connector On ECMO Soft Shell Reservoir Bag
REPORT NO
029
Sorin Inspire 8F Blood Leak From Temperature Port
REPORT NO
028
Sorin Inspire 8F Oxygenator Detached From Holding Arm
REPORT NO
027
Paragon Oxygenator Gas Inlet Leak
REPORT NO
026
Maquet IABP Console Failure
REPORT NO
025
Sorin EOS Gas To Blood Leak Whilst Priming
REPORT NO
024
Chalice Paragon Midi Heat Exchanger Leak Whilst Priming
REPORT NO
023
Chalice Paragon Heat Exchanger Water To Blood Leak
REPORT NO
022
Vent Pump Boot Tubing Inserted In Wrong Way Round
REPORT NO
021
Paragon Oxygenator Heat Exchanger Leak
REPORT NO
020
S3 E62 Pump Error
REPORT NO
019
Medtronic Potential Oxygenator Leak
REPORT NO
018
Medos Heat Exchanger Leak
REPORT NO
017
Avant D903 Has A Dual Chamber Reservoir Leak
REPORT NO
016
Additional Sucker Incorrectly Placed In Raceway
REPORT NO
015
Large Perished Tear Observed On Tubing At Back Of Vaporiser
REPORT NO
014
Gas Blender Flow Control Immobilised
Perfusion Report cards are shown in batches of 30 at any one time where available.
133
132
131
130
129
128
127
126
125
124
123
122
121
120
119
118
117
116
115
114
113
112
111
110
109
108
107
106
105
104
103
102
101
100
099
098
097
096
095
094
093
092
091
090
089
088
087
086
085
084
083
082
081
080
079
078
077
076
075
074
073
072
071
070
069
068
067
066
065
064
063
062
061
060
059
058
057
056
055
054
053
052
051
050
049
048
047
046
045
044
043
042
041
040
039
038
037
036
035
034
London Core Review Cardiothoracic Surgery Course - Touch icon
London Core Review Cardiothoracic Surgery Course - Help Guide
Know the report number? Scroll horizontally through the circle icons and select to view the appropriate report.