Boy died after surgery

Richard Ensor died a month after surgery

A 13-year-old boy died after surgery to his abdomen, an inquest heard.

Richard Ensor, from Bideford, Devon, died of a pulmonary haemorrhage on 14 August 2001, just over a month after the operation at Bristol Children's Hospital.

During that time Richard developed an infection that caused damage to his liver and made his health "desperate".

His mother Susan Haworth told the Bristol hearing the surgeon had said he had nicked the liver and spleen during the operation but had not nicked the stomach.

Bristol Coroner Paul Forrest heard on Tuesday that Richard was born with a condition where his oesophagus was divided from his trachea, which caused him to regurgitate stomach juices, known as refluxing.

He was fit and well after the operation

Susan Haworth, Richard's mother

Richard's mother, Susan Haworth, said he had undergone an operation at the age of four and the condition had caused him to grow normally but that his height and weight "were on the bottom line" of normal.

Richard agreed to have an operation in 2001 that would hopefully stop him refluxing and help him continue to grow, he said.

Richard Spicer, a consultant paediatric surgeon at Bristol Children's Hospital, who had been Richard's consultant since 1995, carried out the operation on 11 July 2001.

Mrs Haworth said: "He was fit and well after the operation. Mr Spicer said it took longer than he had expected."

She added that Dr Spicer had told her he had nicked the liver and spleen during the operation but not that he had nicked the stomach.

Second operation

A test taken on 16 July did not reveal any leaks in the stomach and Richard was fed mashed potato and pasta two days later.

He was also given jelly which nurses later had to drain from his abdomen tube.

Mrs Haworth said Richard immediately complained of stomach pains and had a fever after eating.

Richard continued to feel poorly and a second operation on 21 July revealed "lots and lots of pus", she said.

By 6 August, Richard was having trouble breathing and he eventually died on 14 August of a pulmonary haemorrhage after his family agreed to stop the treatment.

Dr Spicer told the inquest that the purpose of the operation was to divide various adhesions on Richard's stomach, liver and spleen.

He said: "The operation proved to be difficult because of the number of adhesions on the liver, stomach and spleen.

"It is very unlikely there would be a perforation I would not have seen and repaired

Dr Richard Spicer

" It was worse than I expected," he said.

He said perforations could be caused in the stomach during the operation as it was weak, but added: "It is very unlikely there would be a perforation I would not have seen and repaired.

"There was no bleeding or leaking fluid at the end of the operation."

He said a blood test on 19 July suggested Richard was suffering an infection, and that an X-ray taken on 28 July showed a leak in the stomach.

He added that the cause of infection was believed to be a tube, which was replaced on 1 August.

The hearing was adjourned until Wednesday.