Heart-breaking robotic surgery: Patient dies as a result of robotic assisted heart surgery

14 November 2018

In November 2015, a patient died from multiple organ failure following heart surgery performed using a Da Vinci robot.  During the surgery, which took place at the Freeman Hospital, the robot damaged part of Mr Pettitt’s heart, which ultimately resulted in organ failure and tragically, his death.  An inquest took place last week to determine what precisely went wrong, and the coroner’s conclusion was that Mr Pettitt’s death was a “direct consequence of the operation and its complications”, and that his death was in part because “the operation was undertaken with robotic assistance”.  The evidence revealed at the inquest raises important questions about negligence, training policies, and about the use of technology in healthcare in general.  


During the inquest, the surgeon revealed that he “could have done with more dry-run training” on the robot before Mr Pettitt’s surgery, and that the robotics experts (known as ‘proctors’) from Da Vinci, who were supposed to be present throughout the operation, left half way through.  Further, the coroner acknowledged that there was an “absence of any benchmark” for training on new technologies in healthcare, and the Trust’s medical director has issued an apology acknowledging that the Trust “failed to ensure the standard of care that would reasonably be expected”.  

Much of the evidence heard at the inquest will be helpful to Mr Pettitt’s family, should they wish to take legal action against the Trust.  In order to bring a successful negligence claim, it will need to be shown: 

  1. . That the Trust breached their duty to Mr Pettitt (for example, by failing to ensure that the surgeon had undergone the appropriate training before proceeding to operate, and by failing to ensure that a representative from Da Vinci was present throughout the procedure); and 
  2. That, on the balance of probabilities, had the surgeon been trained appropriately, and had the representative been present throughout the operation, there would have been no damage to Mr Pettitt’s heart, and he would not have suffered organ failure and later died. 

Training Policies 

NHS Trusts are responsible for the actions of their employees, which is why legal action is generally taken against the Trust, and not the individual surgeon.  It is therefore surprising that the Trust didn’t have any training policy in place for surgeons carrying out robotic-assisted surgery.  Surely such a policy would be the obvious starting point if the Trust wanted to protect itself?  Fortunately, the Royal College of Surgeons may now be considering whether national guidelines should be introduced to regulate training and the use of robotic-assisted surgery.  However, this reactive response has come too late for Mr Pettitt, who is “more likely than not” to have survived the surgery had ‘conventional’ open heart surgery been performed.  


Technology in Healthcare 

Medical professionals undergo years of training, and I’m sure I’m not alone in thinking that, in an emergency, I would confidently and unquestionably trust any one of them.  But ask me if I’d like to have my heart operated on by a machine, and I would run a million miles.  In my (perhaps old fashioned) opinion, I would always opt to rely on a person over a machine.  But for those of you more open to new ways of thinking, here is a list of things you may wish to think about if you’re offered robotic-assisted surgery:  

  • What training has the surgeon had? 

  • What is the hospital’s policy on robotic assisted surgery and training for surgeons? 

  • How many times has the surgeon carried out this operation? 

  • Has this operation been carried out by anyone else at the hospital/ trust/ anywhere else in the country? 

  • Will there be someone from the technology company supervising the operation, and will they be present for the entire time? 

  • What are the benefits of using robotic-assisted surgery as opposed to “conventional” surgery? 

Personally, I have always found the relentless development of technology terrifying, and often find myself wondering (and worrying about) when it will stop.  When will humans stop developing machinery to do their jobs for them? It seems from this story that humans are capable of doing a much better job themselves.  

If you or a member of your family has experienced a similar situation and would like legal advice, please visit our Medical Negligence and Personal Injury page, or email claims@kingsleynapley.co.uk.

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