Robotic surgery and the coroner

Posted: 05/04/2022

This article is about a failure of surgery and the reassuring benefit of an inquest.

In 2015 Stephen Pettitt, a music teacher, horn player, and occasional music critic for The Spectator suffered severe mitral valve disease, becoming increasingly symptomatic, and surgery was advised.

The consultant surgeon offered a robotically assisted operation, and the patient was informed that this would be the first such operation at the Freeman Hospital, Newcastle.

However, it was also the first time that the surgeon had undertaken a robotically assisted mitral valve repair. The surgeon had spent some time practising with the robotic equipment, but he was not supervised or guided while doing so. He had observed only four such operations done by others in the United States.

There is a practice of arranging so called ‘proctors’ to attend such operations. The point of the proctor is to observe the procedure and intervene if something appears to be going wrong. In this case, there were surgical and anaesthetic proctors arranged by the operating surgeon.

The operation did, unfortunately, go wrong, including misalignment of sutures, inability to correctly position the annuloplasty ring, excessive bleeding, and the unexpected departure of the proctors prior to the operation’s conclusion. Because of these complications, the procedure took much longer than expected, and that delay caused a further injury to the patient. There was also no plan in place to convert to a conventional procedure if difficulties arose. Tragically, as a result, the patient died.

The coroner for Newcastle upon Tyne found that the death was a direct consequence of the operation and its complications. Her conclusion included that the patient died, in part, because the operation was undertaken with robotic assistance. In evidence, the surgeon indicated that he had ceased robotic surgery.

Under regulation 28 of the Coroner’s (Investigation) Regulations 2013, the coroner has the very useful power to issue a report on action to prevent other deaths. This arises where a death occurs due an error or avoidable action which, if repeated, is likely to lead to more fatal outcomes. In this case, the coroner did issue such a report in November 2018 addressed to the chief executive of the Royal College of Surgeons.

In response, the Royal College of Surgeons made the point that it had previously called upon the Department of Health and Social Care and the General Medical Council to publish national guidelines on the introduction of surgical innovation. It responded to the coroner’s report, but issued its own detailed guidelines in 2019.

In the context of the risks involved, it was emphasised that in obtaining consent, the points to discuss with the patient include:

• The innovative nature of the procedure.
• The surgeon’s ‘learning curve’, and his or her experience of the procedure.
• The risks and benefits of the procedure, including unknown and unforeseeable outcomes because of the experimental nature the procedure.

The surgeon should also discuss alternatives including the traditional procedure and, importantly, the choice of no procedure.

The Pettitt inquest showed appalling clinical management and application of a new procedure. Hopefully, the Royal College guidelines will help avoid similar failures in the future.

Litigation arising from robotic surgery injuries is widely reported in the United States, sometimes in very similar circumstances to this case. Penningtons Manches Cooper would be happy to discuss any potential complaint of injury following such innovative surgery.

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