Tools blamed for op girl's death

Bethany suffered from a hereditary condition called spherocytosis

A young girl died during surgery to remove her spleen when a vital blood vessel was ruptured by an "unspecified surgical instrument", a coroner ruled.

Bethany Bowen, five, from Cricklade, Wiltshire, suffered a collapsed aorta during the procedure at the John Radcliffe Hospital in Oxford in 2006.

The keyhole operation was meant to cure her anaemia, but she started bleeding and she died less than a hour later.

The coroner said that the fatal injury was caused during the surgery.

The girl's father said risks taken during the operation had been "simply incredible" and that he had little faith that any lessons would be learned.

Rotating scalpel

Oxfordshire Assistant Deputy Coroner Dr Richard Whittington said it seemed unlikely that a new device was responsible.

Surgeons were using a morcellator, a type of rotating scalpel, to break down the organ.

One of the three surgeons on the team had experience of the device but the doctor using the instrument had seen it for the first time that day.

We have learned from this tragedy and have put those lessons into practice Oxford Radcliffe Hospitals NHS Trust

The inquest heard that the surgeon had received the necessary training.

Gordon Mackinlay, consultant paediatrician at Edinburgh's Royal Hospital for Sick Children, told the inquest it was "improbable" that the device was responsible.

He said that other instruments, the "graspers" and "retractors", had probably caused the damage.

Recording a narrative verdict, the coroner said that the girl had died as a result of surgical trauma caused by, "an unspecified surgical instrument."

A video of the operation, showing the instruments as they were used inside her body, showed no evidence of the cut being made.

'No consolation'

Dr Whittington said Mr Mackinlay's suggestion was "just a theory but a plausible one".

He said that without direct evidence of how the wound was caused the court could not be certain.

But he added: "I do not feel that the morcellator was the cause of the fatal injury."

The coroner said he would not be making any recommendations about future practice because, "doctors already do consult together" about new procedures.

The attitude of the trust was truly appalling Richard Bowen, Bethany's father

Bethany's parents are planning to pursue a clinical negligence claim against Oxford Radcliffe Hospitals NHS Trust.

Her father Richard Bowen said: "We have little faith that lessons will be learned until there is an independent body that monitors surgical training in the NHS, with real power to punish those that don't abide by the rules.

"The risks that were taken by the trust during the operation on Bethany were simply incredible and the attitude of the trust was truly appalling."

A spokesperson for Oxford Radcliffe Hospitals NHS Trust said the trust had admitted legal liability for Bethany's death.

He added: "An operation of this nature will never be without risk, particularly when carried out on such a young child.

"Although this will be no consolation to the family, we have learned from this tragedy and have put those lessons into practice."