Page last updated at 16:33 GMT, Thursday, 8 April 2010 17:33 UK

'Pinkie' operation death 'could have been prevented'

Victoria Infirmary sign
Mr Ewing died during the operation at the Victoria Infirmary in 2006

The death of a man during a routine hospital operation on his little finger could have been avoided, according to an inquiry.

Gordon Ewing, 44, from Cambuslang, died while being treated at the Victoria Infirmary in Glasgow in May 2006.

A fatal accident inquiry heard how he swelled up and turned bright red after being given too much oxygen.

Sheriff Linda Ruxton said his death could have been prevented if anaesthetists had simply woken him up.

The inquiry at Glasgow Sheriff Court heard that the father-of-two was pumped with oxygen at a rate of 15 litres per minute, seven times what he should have received.

The 44-year-old's face, arms and eyelids swelled rapidly before both of his lungs collapsed.

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
Sheriff Linda Ruxton

In a written determination Sheriff Ruxton said that there were "reasonable precautions" which might have prevented Mr Ewing's death.

The sheriff said: "The termination of the anaesthetic procedure thereby allowing Mr Ewing to waken up was a reasonable precaution which might have prevented his death.

"There were several opportunities when that decision could and should have been taken.

"In circumstances where the procedure should undoubtedly have been abandoned and the patient allowed to waken, this option was not at any point considered by any of the three experienced anaesthetists.

She added: "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."

Proper training

Sheriff Ruxton also stated that unclear instructions on the appropriate rate of oxygen also contributed to Mr Ewing's death.

She said: "Had the instruction been given to deliver the oxygen at a rate of two litres per minute, the risks would have been significantly reduced."

The sheriff added that the use of a Cook catheter to intubate Mr Ewing for surgery may also have contributed to his death as no-one was properly trained to use it.

The inquiry earlier heard from consultant anaesthetist Deepa Singh who told the court that the catheter was inserted into Mr Ewing's throat after there were complications intubating him for the operation.

She then decided that Mr Ewing should be given oxygen through the catheter.

Prosecutor Kate O'Sullivan asked Miss Singh who linked up the oxygen and she replied that a nursing sister did it.

Miss O'Sullivan then asked: "Did you give a direction as to what rate the oxygen should be administered to Mr Ewing?"

The consultant replied: "I didn't."

Miss O'Sullivan asked: "Did you check at what rate she had set the oxygen flow?"

'Family man'

Miss Singh replied: "No I didn't, it was an instruction I had given and the person doing it would usually ask me if they were in any doubt."

A short time later Miss Singh noticed that Mr Ewing was swelling up.

Miss Singh said that she initially thought Mr Ewing was having an allergic reaction to drugs he had been given but attempts to treat him with adrenalin were unsuccessful.

The petrol station owner died after suffering a cardiac arrest and two collapsed lungs.

The inquiry heard from Mr Ewing's cousin Duncan Taylor who said it was a "death that should not have happened".

Mr Taylor added: "His younger son still asks where he is. He was an avid family man. He took delight in interacting with them as he was very outgoing."

Since Mr Ewing's death, hospital staff have been told to make sure that they are properly trained in a piece of equipment before using it.

A spokesman for NHS Greater Glasgow and Clyde said: "We remain deeply sorry for the death of Gordon Ewing in May 2006.

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

"We have fully addressed all the shortcomings that have been identified in the intervening period."

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