Experts who were supposed to assist surgeons carrying out the first robotic heart valve operation of its kind in the UK left the hospital theatre before the procedure was finished and the patient died days later, an inquest has heard.
A major investigation was launched by Newcastle Hospitals NHS Foundation Trust following the death of Stephen Pettitt, 69, from Whitley Bay, North Tyneside, at the Freeman Hospital in March 2015.
He suffered multiple organ failure after the procedure led by heart surgeon Sukumaran Nair and the incident was investigated by police, the inquest at Newcastle Civic Centre was told.
It was later found Mr Nair had been offered training on the use of the robot with the hospital’s gynaecology department, but he did not take it up.
He told a colleague later he could have done more “dry-run” training beforehand, the hearing was told.
Expert assistants in the use of the sophisticated Da Vinci robot, known as proctors, were present for only some of the procedure on Mr Pettitt, but left part-way through.
The proctors were not from the manufacturer Intuitive Services, but a different firm called Edwards Lifesciences.
Paul Renforth, a co-ordinator in the use of robotics at the Freeman Hospital, told the inquest the proctors left without any staff being aware they were going.
Mr Renforth, who was in and out of theatre, told coroner Karen Dilks the atmosphere in the room was tense.
After Mr Pettitt died, the co-ordinator said Mr Nair rang him to say he felt “very sad” and that “the procedure had not gone as planned”.
Mr Renforth added: “(He said) possibly he could have done some more dry-run training.”
The operation was planned to repair a mitral valve but damage was caused to the interatrial septum.
The procedure had to be converted to an open heart operation where the chest was opened up to repair the tear.
Pathologist Nigel Cooper said: “By that time the operation had been going on for a considerable period of time. By the end of the surgery the heart was functioning very poorly.”
Medicines and a machine to help the heart function were brought in but Mr Pettitt’s organs began to shut down and he could not recover.
Mr Pettit’s wife, sister and daughter were at the inquest.
Simon Haynes, the trust’s clinical director of cardiothoracic services, said Mr Nair had approached him the month before to be allowed to carry out the robotic mitral valve replacement.
Dr Haynes said agreed “slightly hesitantly” having weighed up the concerns but with the knowledge that proctors would be present.
After it went wrong, the trust launched a major inquiry, he said.
His inquiries formed part of a serious incident review which made recommendations, including making sure there was a firm strategy over when robotic surgery should switch back to conventional methods if there were problems.
Professor Naeem Soomro, director of robotic surgery, said the trust has operated with robots 2,500 times, with more than 30 surgeons trained in their use, and it was a national leader in the field.
Robotic surgery was an extension of what was commonly referred to as keyhole surgery, he said.
The five-day inquest continues on Tuesday.