Max Haigh
PFD Report
Historic (No Identified Response)
Ref: 2016-0082
Coroner's Concerns (AI summary)
Inadequate and incomplete surgical notes failed to detail a ventricular septal defect, risking future surgeons lacking vital information for subsequent operations.
View full coroner's concerns
In the circumstances it is my statutory duty to report to_you: The being
_ Following surgery the surgeon prepared a note of his operation for the medical records_ It was anticipated that Max may, in the future, require further surgery _ The note of the surgery was unsatisfactory and failed to set out:- (a) position of the ventricular septal defect ("VSD") and how it was enlarged; b) A full description of the VSD; position of the tricuspid valve; techniques that were used by the surgeon himself (2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery.
_ Following surgery the surgeon prepared a note of his operation for the medical records_ It was anticipated that Max may, in the future, require further surgery _ The note of the surgery was unsatisfactory and failed to set out:- (a) position of the ventricular septal defect ("VSD") and how it was enlarged; b) A full description of the VSD; position of the tricuspid valve; techniques that were used by the surgeon himself (2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery.
Sent To
- St James’s University Hospital
Response Status
Linked responses
0 of 1
56-Day Deadline
26 Apr 2016
About PFD responses
Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.
Source: Courts and Tribunals Judiciary
Report Sections
Investigation and Inquest
On 24th June 2013 an investigation into the death of Max James Haigh was commenced_ investigation concluded at the end of the Inquest on 5th February 2016. The conclusion of the Inquest was a Narrative Conclusion; the medical cause of death 1(a) Multiorgan failure (due to heart failure), (b) Cardiomegaly with myocardial fibrosis and lymphocytic myocarditis and (2) Previous cardiac surgery for complex congenital cardiac anomaly and pulmonary regurgitation:
Circumstances of the Death
Max Haigh was born 11th April 2012. He had a complicated cardiac defect; including a double outlet right ventricular septal defect; pulmonary stenosis and a left sided superior vena cava to the left atrium On 18" March 2013 he underwent surgery and an unsuccessful attempt was made to perform a double ventricular repair. (In the event a pulmonary band was fitted). The surgery was performed competently. He was discharged from hospital on the 11lh April 2013 and his subsequent recovery was unremarkable before he presented to hospital on the gth June 2013 with a history of vomiting and being unwell He remained in hospital until the 12th June 2013 when his condition deteriorated _ Attempts at resuscitation were unsuccessful and death was pronounced at 2310 hours on 12th June 2013. At post mortem significant findings were that he had multiple organ failure; an enlarged heart (cardiomegaly) , myocardial fibrosis and lymphocytic myocarditis_
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you [ANDIOR your organisation] have the power to take such action.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.