“During the inquest evidence was heard that i) ii) iit) v) vi) The damage to the spleen…”

The coroner’s concerns

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(1) During the inquest evidence was heard that i) ii) iit) v) vi) The damage to the spleen was unlikely to have been due to the malfunctioning of the operating table. During the surgery the operating table moved uncontrollably without operation of the handset until it stopped in the Trendelenburg position. The handset was last serviced by the Eschmann Group on the 14” December 2012 when no defects were identified but after that date the handset had been opened at some point. The handset is not a serviceable item and the handsets are replaced as sealed units only and are not repairable. The opening of the handset can compromise the seal that protects the circuit board and the button contacts from fluid ingress. There was evidence of tarnish on the handset Trendelenburg button electrical contacts within the handset indicating possible moisture ingress at this point. ‘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. ‘The bracket to attach the handset to the side of the operating table was missing at the time of inspection after the incident. 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. The Eschmann Group confirmed that the emergency stop button is not isolated from the circuit board within the handset nor within the handset itself to ensure that It operates separately from other functions within the headset. Over the last 5 years the Eschmann Group has recorded 6 other incidents of unrequested powered table movement in relation to operating tables with 4 incidents where no fault was found and the issue could not be replicated. One incident was traced to handset damage and one incident traced to possible fluid ingress into a circuit board. In the case of the incident relating to the deceased no explanation could be given for the malfunction of the operating table other than possible fluid ingress but there was no evidence of fluid on the floor of the Operating Theatre at vii) ‘the time of surgery and the table had functioned without incident in relation to surgical procedures on previous days. The Royal Albert Edward Infirmary has similar operating tables with similar handsets in the Hospital but no review has been carried out by the Hospital in relation to those operating tables and handsets, particularly as to whether the handsets have been opened with damage to the seals. vill) Whilst pre-operation checks of equipment are conducted by Surgical and Theatre teams at the Hospital 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. Training and Auditing are required in relation to such matters. The incident was reported to the Medicines and Healthcare Products Regulatory Agency (MHRA) who conducted an investigation but the conclusions of the investigation and any guidance has not been shared with the Wrightington, Wigan & Leigh NHS Foundation Trust. There appeared to be very little, if any, contact between the MHRA, the Eschmann Group and the Wrightington, Wigan & Leigh NHS Foundation Trust to enable the sharing of information for lessons to be learned and actions to be taken. (2) [have concerns with regard to the Wrightington, Wigan & Leigh NHS. Foundation Trust in relation to ) ii) iii) v) 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. Pre-operation checks of equipment particularly the function of handsets attached to operating tables with particular attention to the general condition of the handsets, the seals, and the position of the handsets at the side of the operating table to avoid the handsets being placed on the floor of the Operating Theatre to reduce the risk of fluid ingress. The procedures relating to inspection of operating tables and handsets used at the Hospital particularly to identify any damage to the handsets to ensure the immediate replacements of any damaged handsets. The training of staff in relation to pre-operative checks of equipment in the operating theatres at the Hospital with emphasis on operating tables and handsets including the correct positioning of the handsets with effective auditing of such inspections. (3) have concerns with regard to the Eschmann Group in relation to a review of the operation of handsets attached to operating tables in view of the number of unexplained and uncontrolled movements of operating tables with particular reference to the isolation of the emergency stop button on the handsets to ensure that the emergency stop button operates in all circumstances whether there is damage to other parts of the handset. (4) I have concerns with regard to 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.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2013-0367

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8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0