Baby died as heart machine blew up

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The Independent Online
A LEADING heart surgeon has called for tougher controls on hospital staff who operate heart-lung machines after an accident in which a baby bled to death.

Sir Magdi Yacoub, the heart transplant pioneer, has written to the Department of Health, complaining about the delay in regulating perfusionists, the medical scientists who operate the highly complex equipment that keeps patients alive during open-heart surgery.

The move comes after a perfusionist at Guy's Hospital, London, was sacked because of concerns about his competence because of the deaths of two patients, including the baby who bled to death, and a third incident in which a patient's life was put at risk.

Muhammed Majeed was not accredited by the Society of Perfusionists and was suspended in June after a surgeon operating on a child at Guy's noticed he had connected two tubes the wrong way round. The error was quickly corrected and the patient was unharmed.

A couple of weeks earlier, on 16 May, four-month-old Hannah Shepherd died after the heart lung machine on which she was being kept alive blew apart, covering nurses in blood.

An inquest into her death at Southwark Coroner's Court yesterday heard that Mr Majeed had inserted a haemofilter into the circuit in an unconventional way, which may have increased the pressure and caused the machine to fail.

However, the coroner returned a verdict of death by natural causes after a pathologist said a post-mortem examination on Hannah showed she would have died even if the machine had not failed.

In February 1997, Mr Majeed was involved in a case in which a woman died after air was accidentally infused during a heart operation. The causes of that incident are still being investigated.

A spokeswoman for Guy's and St Thomas' NHS Trust said Mr Majeed had been hired from South Africa, where he had received five years' training and 12 years' experience. He had also come with good references. However, he was not accredited by the UK Society of Perfusionists and a condition was imposed on his contract that he achieve accreditation in two years.

After he was suspended in June, Mr Majeed was put under close assessment and the trust decided he would not achieve accreditation and sacked him in September.

In a letter to Dr Peter Greenaway, chief scientific officer at the health department, Sir Magdi Yacoub, president of the Society of Perfusionists, said the dangers of perfusion were well known. "I write to you to express my deep concern about the delay in regulating perfusionists. The practice and science of cardiopulmonary bypass has evolved to such a degree that it now deserves to be recognised and strictly regulated." He adds: "Compared with other professionals already regulated I cannot think of a group who have a higher level of responsibility. Without them working to their present high standards all open-heart surgery would cease."

Sir Magdi says urgent action is necessary to resolve the problem.

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