A pensioner died after his chest was bled 'empty' when he was wrongly connected to a blood pumping machine and a hospital worker left the room.
NHS staff failed to use enough clamps to disconnect 76-year-old Dr John Baines from the device after a gruelling six-hour bypass operation, on January 29.
This meant his blood was pumped into the machine, which was filling in for his heart and lungs during the surgery, but not pumped back into his body.Someone will swing for this, surely?
Deputy Assistant Coroner Mairin Casey ruled that no one member of staff was to blame and his death was caused by a 'series of collective errors'.Wha..?
In a bypass operation, the pumps are operated by specially trained health professionals known as 'perfusionists', who work with the surgical team in connecting and disconnecting the machine to the patient.
However, the perfusionist who had been involved in the discussions about the complex operation was replaced before it began by two others, who oversaw the machine during the surgery.
One of them, Andrew Sutcliffe, said they clamped the line from the patient's neck and assumed two other clamps required had been attached by other members of the team.
He said: 'I think the issue is that we had clamped the common line. But clamps hadn't been applied where we would have expected them to.'And you didn't think to check? Somehow, 'professional' isn't the word I'd have used...
Miss Casey recorded a narrative verdict and said the mistake was the result of collective rather than individual error.
She said: 'I'm confident that from the earliest point the human error was acknowledged to the family and to all who needed to subsequently investigate this matter.
'I'm also satisfied that there's no culpability in respect of an individual in this case.'Nice! In effect, so many of you screwed up it'd be 'unfair' to hold any one of you responsible, so you get off with a massive fine (paid for by us taxpayers, of course) and a 'lessons have been learned' statement.