A heart surgeon turned down the chance to train on a pioneering robot he used in an operation in which the patient later died, an inquest has heard.
Sixty-nine-year-old Stephen Pettitt suffered multiple organ failure at the Freeman Hospital, Newcastle in 2015 after the Da Vinci robot-assisted heart valve operation, the first of its type at the trust, went badly wrong.
Yesterday a coroner was told that the lead surgeon, Sukumaran Nair, subsequently admitted to a colleague that he could could have done more “dry-run” training on the sophisticated system.
It also emerged that robotics experts tasked with assisting the surgical team left part-way through the operation without informing staff.
The death of Mr Pettit, from Whitley Bay, North Tyneside, sparked a major investigation at Newcastle Hospitals NHS Foundation Trust, including a probe by police.
Robots such as the Da Vinci system are supposed to enable accurate key-hole surgery which should be safer and hasten the patient’s recovery time.
The operation in 2015 was performed to repair a mitral valve, however damage was caused to the interatrial septum, forcing the team to open Mr Pettitt’s chest in order to repair the tear.
Pathologist Nigel Cooper said: “By that time the operation had been going on for a considerable period of time.
“By the end of the surgery the heart was functioning very poorly.”
Medicines and a machine to help the heart function were brought in but Mr Pettitt’s organs began to shut down and he could not recover.
After the patient died, Mr Nair telephoned Paul Renforth, a co-ordinator in the use of robotics at the Freeman Hospital, to say he felt “very sad” and that “the procedure had not gone as planned”, the court heard.
Mr Renforth added: “(He said) possibly he could have done some more dry-run training.”
The co-ordinator, who was present in the operating theatre through parts of the procedure, said the atmosphere was tense.
He also said the expert assistants in the use of the sophisticated Da Vinci robot, known as proctors, were present for only some of the procedure on Mr Pettitt, but left part-way through.
The proctors were not from the manufacturer Intuitive Services, but a different firm called Edwards Lifesciences.
Mr Renforth told the inquest the proctors left without any staff being aware they were going.
Simon Haynes, the trust’s clinical director of cardiothoracic services, said Mr Nair had approached him the month before to be allowed to carry out the robotic mitral valve replacement.
Dr Haynes said agreed “slightly hesitantly” having weighed up the concerns but with the knowledge that proctors would be present.
His subsequent inquiries formed part of a serious incident review which made recommendations, including making sure there was a firm strategy over when robotic surgery should switch back to conventional methods in the event of complications.
Professor Naeem Soomro, director of robotic surgery, said the trust has operated with robots 2,500 times, with more than 30 surgeons trained in their use, and it was a national leader in the field.
There are around 60 surgical robots in NHS hospitals. Lancashire Teaching Hospitals, which has been using a Da Vinci robot for a year, said it noticed a “significant reduction in patient recovery times and complications”.
The five-day inquest, which was attended by Mr Pettitt’s sister and daughter, continues on Tuesday.