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
013
Isoflurane Vaporiser Seal Leak Due To Malposition
REPORT NO
012
1/2/13
Hypercoagulable Disorder May Have Led To Oxygenator Failure
REPORT NO
011
1/1/13
LV Vent Placed In Raceway In Wrong Direction
REPORT NO
010
1/3/12
Sucker Placed In Raceway In Wrong Direction
REPORT NO
009
1/2/12
Similarity In Heparin And St Thomas Cardioplegia Ampules
REPORT NO
008
1/7/11
Aorta Remained Clamped Post CPB
REPORT NO
007
1/5/11
Deficiencies In The QC At Terumo Ann Arbor, USA.
REPORT NO
006
1/4/11
Awareness Of Suckers When Using Bio-Glues
REPORT NO
005
1/2/11
Patient Exsanguinated From Additional Venous Line Post CPB
REPORT NO
004
1/1/11
Possible Inaccuracies In Colloid Research
REPORT NO
003
1/2/10
Difficulties In Visualising Blender Reading
REPORT NO
002
1/1/10
Luer Cap Found In Venous Inlet Port
REPORT NO
001
1/1/09
Oxygenator Water To Blood Leak
Perfusion Report cards are shown in batches of 30 at any one time where available.
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