Kenneth Smalley
19 Dec 2013 · Coroner Alan Walsh · Manchester (West)
The coroner's concerns
1. uncontrolled movement of operating table
“During the surgery the operating table moved uncontrollably without operation of the handset until it stopped in the Trendelenburg position”
2. emergency stop button failure
“The handset emergency stop button should stop the movement of the operating table at all times but on this occasion the emergency stop button did not cause the operating table to stop”
3. handset placed on floor causing fluid ingress risk
“The handset had been left on the floor of the Operating Theatre and not in the correct position on the side of the operating table”
4. inadequate pre‑operation checks of handsets
“pre-operation checks of equipment are conducted by Surgical and Theatre teams at the Hospita! prior to each surgical procedure, the checks do not appear to cover the position of the handsets or whether the handsets had previously been opened or subjected to tamper”
5. lack of comprehensive review of equipment
“The function of operating tables and handsets particularly the review of all operating tables and handsets used at the Hospital following the incident on the 27" March 2013”
6. failure to share investigation findings
“the Medicines and Healthcare Products Regulatory Agency in relation to contact with all interested Agencies following an investigation to ensure the sharing of information with all interested Agencies particularly to enable lessons to be learned and corrective action to be taken as soon as possible”