Max James Haigh · Prevention of Future Deaths report

On 24th June 2013 an investigation into the death of Max James Haigh was commenced. The investigation concluded at the end of the Inquest on 5th February 2016. The conclusion of the Inquest was a Narrative Conclusion, the medical cause of death being 1(a) Multiforgan failure (due to heart failure), (b) Cardiomegaly with myocardial fibrosis and lymphocytic myocarditis and (2) Previous cardiac surgery for complex congenital cardiac anomaly and pulmonary regurgitation.

1. Max Haigh was born 11th April 2012.
2. He had a complicated cardiac defect, including a double outlet right ventricular septal defect, pulmonary stenosis and a left sided superior vena cava to the left atrium. On 18th March 2013 he underwent surgery and an unsuccessful attempt was made to perform a double ventricular repair. (In the event a pulmonary band was fitted). The surgery was performed competently.
3. He was discharged from hospital on the 11th April 2013 and his subsequent recovery was unremarkable before he presented to hospital on the 9th June 2013 with a history of vomiting and being unwell.
4. He remained in hospital until the 12th June 2013 when his condition deteriorated. Attempts at resuscitation were unsuccessful and death was pronounced at 2310 hours on 12th June 2013.
5. At post mortem significant findings were that he had multiple organ failure, an enlarged heart (cardiomegaly) and myocardal fibrosis and lymphocytic myocarditis.

(1) Following surgery the surgeon prepared a note of his operation for the medical records. It was anticipated that Max may, in the future, require further surgery. The note of the surgery was unsatisfactory and failed to set out:-
(a) The position of the ventricular septal defect (”VSD”) and how it was enlarged;
(b) A full description of the VSD;
(c) The position of the tricuspid valve;
(d) The techniques that were used by the surgeon himself.

(2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery.