A Watford man who injured his head falling from a lorry “could not have been stabilised” even before the freak failure of a piece of medical equipment keeping him alive.
The second day of an inquest into the death of Anthony Cook, from Bradshaw Road, took place in Hatfield Coroner’s Court yesterday.
After he fell from a lorry on July 28, 2009, Mr Cook was taken to the QEII Hospital in Welwyn Garden City and later transferred to the Royal Free Hospital in London, where he passed away on August 4.
During his stay in the Royal Free, a pump delivering the drug noradrenalin, which was controlling his blood pressure, failed momentarily before a backup could be started the night before Mr Cook died.
Mr Mansour, intensive care nurse of 20 years, said: “Mr Cook's blood pressure was coming down so he was on noradrenaline to increase it. He required high doses, the maximum dose, to maintain normal blood pressure.
“We normally run two pumps, one on standby. As Mr Cook was on such a high dose, to stop the pump even for a moment would be catastrophic, it would have a massive effect on the patient.
“I had to increase the rate of the pump two or three times before midnight, and then update the chart, which was half a meter or less away.
“Suddenly I heard an unusual alarm to do with the pump, it said the machine was faulty and shut down, and I had to start the second pump.
“I called for assistance, we started CPR as the heart rate was very low, Mr Cook responded quite quickly and his blood pressure was stable again after about half an hour to an hour.
“These pumps can go faulty at any minute, we cannot guarantee it won't fail. There have been 10 to 15 incidents in my time, although not as serious as this.”
Colin Shieff, a consultant neurosurgeon at the Royal Free, said Mr Cook's reaction to the failure of the pump confirmed that there was no hope of reviving him.
He said: “His brain was already terminal and unable to function, it was only the noradrenalin which was keeping his heart going.
“What this failure did was reveal a heart which was unable to work on its own without massive chemical support, he could not have been retrieved or stabilised, or achieved any other outcome other than death.
“Falling from above your height has the potential to be catastrophic. Surgery was proposed and undertaken, we hoped he might survive but had no degree of certainty."
The next morning Mr Cook was taken off sedation, had a further cardiac arrest and died.
Mr Shieff added: “It was known that when that happened his heart would stop.”
Andrew Pritchard, service manager for Braun, the manufacturer of the pump, said the failure was “very unusual” with no other recorded incidents for any of the other 134,000 units in use.
“There are two computers, one which controls the function of the pump and one which monitors the action of the pump. One of the computers failed to respond to the other. The unit shut itself down and made itself safe, as well as emitting an audible and visual alarm.
“The unit has a log, which shows the last 1,000 events. We have simulated the same sequence of key presses but could not reproduce the fault.”
The inquest continues today.
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