NHS 'to learn from girl's death'

A doctor did not know stay sutures had been used, the coroner said

Lessons will be learned after surgery on a toddler went wrong at a Brighton hospital, an NHS trust has said.

It follows an inquest where the coroner said the death of 20-month-old Indya Trevelyan was by medical misadventure.

She died in April after surgery at the Royal Alexandra Children's Hospital. The coroner said a doctor did not have knowledge of sutures that was needed.

Brighton and Sussex University Hospitals NHS Trust said it was looking at the implications of the verdict.

After the inquest, Matthew Fletcher, medical director at the NHS Trust said: "This type of catastrophic incident changes the way we practise medicine and we will do everything we can to ensure the same sequence of events can never happen again.

"Our thoughts and sympathies continue to be with Indya's parents and family."

'Rare operation'

Outside the coroner's court, Indya's father, Nigel Trevelyan said he and his wife, who live in Pease Pottage, West Sussex, were considering legal action.

He said: "Losing our lovely daughter was devastating, but discovering that her death was preventable was unbearable."

Indya's mother, Sian, said: "I just want to get back to remembering Indya as she was, and remember her life rather than her death."

The inquest heard that Indya was admitted with a severe cough and breathing problems caused by the respiratory illness, croup, and paediatricians inserted a breathing tube.

Indya's parents said they were considering legal action

But after the surgeons had left the operating theatre, on-call doctor Dr David Campbell did not recognise a technique that had been used to stitch the tube to Indya's chest.

When it came loose he pulled it off, ripping stitches from her body, the inquest was told.

Dr Campbell alerted the other surgeons, but Indya suffered a cardio-respiratory arrest and died the next day.

Coroner John Hooper said: "What was critical at this point was the need for knowledge of the presence of stay sutures.

"Dr Campbell did not have that knowledge. He did not have the experience of stay sutures and having arrived later to the scene did not have the benefit of seeing Dr MacDonald use them.

"None of the consultants thought to ask Dr Campbell if he knew about the stay sutures and their purpose, or to tell him what they were there for before leaving Dr Campbell with any eventuality that might arise during the post-operative period."

He added: "It would have been helpful if at least one of them had remained during the waking-up period."

'Best interests'

Mr Hooper said the operation was a very rare one to be used outside specialist hospitals in London, but staff at the Royal Alexandra Children's Hospital had no choice but to go through with it.

But he added: "It is clear from the evidence that when the consultants embarked on the events that have been described, they did so with Indya's best interests in mind."

Mr Hooper said he would be writing a letter to the NHS Trust under Section 43 of the Coroner's Act, expressing his concern of the risk of other deaths occurring in a similar way in the future.

Indya died from multiple organ failure at Evelina Children's Hospital in London, where she was moved to after the operation in Brighton.