Patient 'blown up like a balloon' could have been saved by doctors

Published on Thursday 8 April 2010 22:55

DOCTORS could have saved the life of a man who died during an operation on his little finger by simply waking him up, a sheriff has ruled.

Father-of-two Gordon Ewing was effectively "blown up like a balloon" during the routine procedure on his pinkie in May 2006 after anaesthetists pumped too much oxygen into his chest and punctured one of his lungs.

Yesterday, Sheriff Linda Ruxton, in a formal finding after a fatal accident inquiry held last year, reported that doctors could have resuscitated Mr Ewing even as his operation went badly wrong.

She concluded: "No thought was given by anyone to terminate the procedure and waken him, despite this being described as an absolutely fundamental option available to all anaesthetists.

"Although the choice to waken a patient may seem so basic and so obvious that anaesthetists need no reminding, the tragic circumstances of Mr Ewing's death would tend to suggest otherwise."

Mr Ewing, a 44-year-old petrol station manager from Cambuslang, underwent the operation at Glasgow's Victoria Infirmary six weeks after breaking his finger when playing with his two-year-old son.

His family had expected the procedure to be straightforward. Speaking on their behalf, Mr Ewing's cousin Duncan Taylor told the inquiry the death "shouldn't have happened at all". He added: "His family is devastated. His younger son still asks where he is. He was an avid family man. He was very family-orientated."

Sheriff Ruxton, in her 90-page determination, detailed the entire procedure, stressing that Mr Ewing weighed 19 stones and was deemed overweight. This meant that anaesthetists working on him had used special equipment with which they were less familiar.

Medical staff inserted a "Cook" catheter into Mr Ewing's airway. During the operation, the catheter slipped down and punctured his right lung. Oxygen – seven times more than he needed – was then "allowed to flow directly into the tissues". Mr Ewing, as a result, suffered two collapsed lungs and a heart attack.

His chief anaesthetist, consultant Deepa Singh, told the inquiry that Mr Ewing had swelled up, his face and eyes bulging, and turned red. She initially thought he was suffering an allergic reaction to medication.

Sheriff Ruxton reported that Mr Ewing's death had "had a profound effect on Dr Singh personally and on the team". Anaesthetists in Glasgow have now "learned their lessons".

Sheriff Ruxton, however, has asked for her findings to be passed on to the Royal College of Anaesthetists.

She added: "Mr Ewing's death occurred in highly unusual circumstances which arose from a combination of events which are unlikely ever to be repeated."

Yesterday, a spokeswoman for Greater Glasgow and Clyde Health Board said: "

We fully accept all of the sheriff's findings. In particular, we accept that errors were made in Mr Ewing's care."

Mrs Ewing was not available for comment. The family has previously indicated that it will sue the health board for damages.

MISDIAGNOSIS

&#149 Four-month-old Jerome MacInnes died in 2005 after doctors at the hospital failed to spot that he had meningitis and instead sent his mother home from hospital with just a bottle of Calpol for him.

&#149 In 2001 Kirsty Thomson, 13, succumbed to suspected peritonitis just three days after being discharged from the hospital, following five days treatment for acute stomach pain.

&#149 Staff were accused of incompetence in the death of Imran Khan, 17, in 1998, when they failed to detect blood poisoning, caused after a chest drain was improperly moved.