Using a device without training may have cost a young girl her life
Posted Oct 05 2009 10:03pm
The January 6, 2009 issue of the Daily Mail (a British newspaper) relates the story of a five year old girl with hereditary spherocytosis who presented for elective splenectomy. Multiple family members had the disease and had undergone the procedure in the past without complication. The plan was to remove the spleen laparoscopically. According to the article the surgical team decided to use a device that had been designed to morselize the uterus to ease removal during laparoscopic hysterectomy. Neither the surgeon nor the surgical resident had specific training in the use of the device. In addition the device had never been used on a child. Somehow during the procedure the aorta was cut in two places and the girl died of hemorrhage. Because the operation took place in Great Britain, the settlement was only about $15,000 and this was based on the lack of informed consent related to the use of the new device. The court did not find for the plaintiff despite the fact that the spleen, the disposable parts of the device, etc. were all “lost,” that the physicians present seemed to change their account of events as time progressed, and that the family was not given access to any of the OR nurses. The case emphasizes the risk inherent in “trying” new procedures, devices or techniques without informing the patient, obtaining appropriate training or thoroughly considering the risks.