Infant Dies When Heart Machine Accidentally Switched Off by Doctor

By Steven DiJoseph

British Health Officials Reeling from Growing list of Serious Medical Blunders

Four-month-old Thomas Smith never had a chance. He was simply “let down in a number of ways” by the very people who were supposed to be caring for him.

After being born with Down’s syndrome, the child suffered a heart attack when a hospital ventilator failed. He was successfully resuscitated and hooked up to a heart-lung bypass machine in order to give his tiny body a chance to rest and recover.

When Dr. Simon McGuirk, who was not qualified to operate, restart, or even monitor the machine, opened the lid to clean it (for some unknown reason), the machine switched itself off.

The doctor called for help only to find that no one duty in the unit had any idea how to operate or correctly restart the machine either. Apparently, the hospital did not have the resources to have a qualified operator on duty at all times when the machine was in use.

When the machine was eventually restarted, it was incorrectly put in reverse mode so that it started pumping oxygenated blood into the infant’s body. This happened because the one doctor, who was trained to operate the machine, could not remember which color buttons to push when he was telephoned.

Thus, McGuirk was left to guess whether it was the two orange or the two blue buttons that needed to be pushed. He pushed the two blue buttons. Unfortunately for little Thomas, McGuirk guessed incorrectly thereby snatching away any chance the child had to survive this tragic comedy of errors.

McGuirk’s admitted “stab in the dark” sealed the boy’s fate. Thomas Smith died from heart failure, brain damage, and heart disease according to the opinion of Dr. Phillip Cox a consulting pathologist.

The coroner’s inquest before the Birmingham Coroner’s Court is not scrutinizing some isolated medical error, however. Rather, it is in the unenviable position of having to investigate the latest in a series of horrendous mistakes that have been reported in the UK since September of last year.

Only last week, we reported on the facts leading up to the removal of the wrong (healthy) kidney of a 63-year-old cancer patient, John Heron, who claims to have told his doctors that the pain is was having was on his left side and not his right side that had been marked for surgery.

Heron was told not to worry despite the fact that his doctors had not reviewed X-rays that clearly showed the cancerous tumor was on Heron’s left kidney.

Following the surgery, Heron was even told that he was “a lucky man.” The next day, however, he was told the terrible news after the pathology lab found the kidney that had been removed to be completely healthy.

Now, as the result of this “disastrous” mistake, Heron faces years of dialysis and an uncertain future. He must await a donor kidney, which could take two or more years and he must undergo additional surgery to remove the tumor and cancerous portion of his left kidney.

In September it was reported by news sources in the UK that 52-year-old Marjorie Patterson had a routine mammogram which supposedly showed a suspicious shadow. After an MRI and biopsy, she was told by telephone that she had an aggressive type of breast cancer.

When doctors advised her that a mastectomy was needed to save her life, she agreed, and the surgery was performed.

Three weeks later, doctors admitted the biopsy they had examined belonged to another patient and that Mrs. Patterson never had cancer.

Also, within the past two weeks, it was announced that Peter Cura had died from kidney cancer that had gone undiagnosed some 37 times over 14 months.

Cura was suffering from severe, chronic back pain and was repeatedly examined by hospital staff at Medway Maritime Hospital in Gillingham, Kent.

Classic symptoms of kidney cancer along with numerous scans and six surgeries repeatedly produced a diagnosis of kidney stones.

It was only Mr. Cura’s persistence that led to him having a CT scan that showed his left kidney had stopped functioning and required removal.

When that surgery was performed, a three inch malignant tumor was finally discovered. Additional tests showed the cancer had already spread throughout Mr. Cura’s body.

Nearly 18 months after his initial visit to the hospital, Cura was told his cancer was incurable. He passed away earlier this month.

Just two weeks prior to his tragic death, the father of two (Lewis, 6, and Abbie, 3) had stated: “I mainly feel anger with the doctor I was seeing at the time. It crossed my mind that it might be cancer. But when I asked the doctor he said, ‘Definitely not.’”

When the kidney was taken out, it was sent for tests. An 8cm tumor was found, yet “we were told there was nothing to worry about. I try not to think about it (dying) too much but I am angry about the way the doctor was so blasé about it.”

Julia, his wife, who may sue the trust that runs the hospital, added: “We want the hospital to admit what they have done and to do something about it so that others don’t have to go through this.”

The family is being represented by Sarah Harman who was quoted as stating: “It is tragic that such a young man with a family should have lost his life in a situation that was avoidable.

“The care provided by Medway Maritime Hospital was far below what he had a right to expect. One mistake can be excused, but in Peter’s case there were a series of lost opportunities when his life could have been saved.”

Although Cura visited the hospital 37 times, often in the emergency and the outpatient departments, the correct diagnosis was never made. Not once at any of these visits was kidney cancer raised as a possible cause.

It was not until December 2003 that he was told the cancer was almost definitely incurable. That diagnosis/prognosis came only after Cura, himself, had insisted on the CT scan that led to his kidney being removed in July 2003.

In a period of less than three weeks between mid-January and February 10, the country was shaken by a series of potentially fatal errors by highly qualified doctors and medical personnel.

This unbelievable sequence of events began when it was revealed that numerous mammograms had been mistakenly read as being cancer-free by the same radiologist working at North Manchester General Hospital in Crumpsall and Tafford General in the UK.

At least 28 woman were wrongly advised their scans were negative when, if fact, they actually revealed the presence of breast cancer in its early and more treatable stages.

At least 17 of those women are now suffering from advanced stages of the disease and are at serious risk of dying as a result of the misdiagnoses. The investigation into the matter only promises to uncover more examples of malpractice by this radiologist.

Less than a week later, came another startling report of misread tests at the same medical trust. This time, hospital officials admitted more than 1,000 patients may have been wrongly diagnosed with heart problems by a cardiac technician at Fairfield General Hospital in Bury, Greater Manchester, when, in truth, the readings were actually normal.

Some 1,053 patients have been notified by the hospital that their records must be re-examined due to errors that were found in evaluating echocardiogram tests.

Dr. Ruth Jameson, acting medical director of Pennine Acute Trust, which runs the hospital, said: “This technician, who was supplied by an agency, is no longer doing any work for the Trust.”

According to Dr. Jameson, not all patients who had undergone ultrasound heart scans were affected. Only those who had seen this specific unnamed technician between May 23 and December 7 are at risk of having inaccurate echocardiograms.

Dr Jameson said: “We are hopeful that the particular echocardiograms will not have had a major adverse effect on patients but the only way we can assure our patients that they are having the appropriate care is to carry out this review.”

The review is expected to take several weeks and hospital officials have not yet determined whether any patients were given the wrong medication as a result of the cardiac technician’s errors.

Then, possibly the most horrendous error in that appalling trilogy came to light with the disclosure that after undergoing months of treatment for a brain tumor, which included 17 sessions of radiation therapy, a 15-year-old girl was given the “all clear” by her oncologists only be told shortly thereafter that she now faces, brain damage, paralysis, and eventual death, not from her cancer, but from the treatment she received.

As it turned out, at each of her 17 radiotherapy sessions Lisa Norris received a massive overdose of radiation.

This horrible mistake (17 horrible mistakes to be more accurate) has left Lisa in constant pain, and unable to sleep. Her red and blistered body is burned to the point where she must take frequent cold showers simply to cool down.

She was literally cooked from the inside with doses of radiation so excessive that she has been told that there is the distinct likelihood she has suffered irreparable brain damage that may leave her paralyzed and eventually kill her in as little as 10 to 15 years.

Ironically, she has been sentenced to a protracted and hideous death by her doctors and not by the cancer from which they were trying to save her.

The hospital, Beatson Oncology Centre in Glasgow admitted that “human error” had led to Lisa being given overdoses at each of her 17 scheduled radiotherapy sessions. Beatson is the second largest cancer centre in the UK and has a global reputation.

According to The Daily Mail, Professor Alan Rodger, the center’s medical director, said: “My colleagues and I deeply regret the error that has led to Lisa Norris being given an overdose of radiation during her course of treatment. The staff involved with his isolated incident is extremely distraught. Initial meetings have taken place with Lisa and her family and we will do everything in our power to support them in the challenges ahead.”

“I’ve been told I could be brain damaged, could be paralyzed and in ten to 15 years I might not be here, I could die,” Lisa said.

“I could have a scar on my head or brain which can lead to strokes, heart attacks and whatever else.

“I don’t know what is going to happen to me, it could happen in the next six months to a year. We just don’t know what is going to happen.

“I’ve got burns on the back of my neck and ears and they’re starting to blister.

“I can’t sleep because I can’t lie on my back. I can’t really do much, my mum has to help me put my clothes on.”

Lisa’s distraught parents are not inclined to simply accept the center’s apology. They want the five staff members responsible for the errors fired.

Lisa also stated (as reported by The Daily Mail):

“I’m really angry with them, they shouldn’t be able to get away with it,” said Lisa, from Girvan, Ayrshire.

“By rights, they should be put out of their jobs and not allowed to work in the NHS ever again because it could happen to somebody else.”

Prior to the bungled radiation therapy, Lisa had undergone chemotherapy that had sickened her and made her hair fall out. Following the radiotherapy, however, Lisa and her parents were told that the tumor was gone.

Shortly thereafter, however, Kenneth and Elizabeth Norris were told that “two consultants were coming to see them.” (Daily Mail). “We knew something was wrong,” said Mrs. Norris, 49. “You never hear of consultants visiting your house, so alarm bells were ringing.”

Her husband said: “It just knocked us for six. We’ve not been able to sleep a night since. If they can do this to Lisa, they can do this to anyone.”

Although there is an ongoing inquiry into this medical blunder by the Department of Health and the radiation protection division of the UK Health Protection Agency, it has not yet emerged how the wrong dose of radiation was administered 17 times.

“But it is thought that the wrong level was given on Lisa’s first session and then repeated because it was written in the notes with no one spotting that it was too high.” (Daily Mail)

Martin Ledwick, of Cancer Research UK, said: “Obviously as a health professional working with cancer patients for a number of years I was very shocked and surprised that this happened as I’m aware of all the checks that are in place to avoid this sort of mistake being made.”

Thus, it is quite understandable that the public’s confidence in the British healthcare system has been badly compromised. The death of little Thomas Smith has only added to the chorus of voices asking: What is allowing so many extreme cases of medical malpractice to occur in the UK at the present time?

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