The heartbroken parents of a two-day-old baby who died after a needless operation today described the horror of their son ‘arriving home in a coffin’.
Paul Mitchelhill died in his mother’s arms following risky abdominal surgery carried out by a doctor who wanted to ‘prove a point’.
A coroner concluded that failings by surgeon Emmanuel Towuaghanste ‘directly contributed’ to his death and the inquest heard he should have acted more ‘conservatively’.
And his devastated parents, Paul and Irene Mitchellhill, have today revealed the agony of their loss which continues to leave a ‘void’ in their lives almost five years on.
Speaking after the inquest, the couple, from Carlisle, Cumbria, said: ‘Paul died the day after his surgery and we came home without our son, having only held him for the first time as he was dying.
‘We faced the horror of losing our first baby boy and the trauma of him arriving home in a coffin.’
Paul and Irene Mitchelhill (pictured at their son’s inquest hearing) have said they had to face the horror of their baby son arriving home in a coffin
The hearing at Newcastle Civic Centre was told how the surgery was ‘not urgent’ and Paul’s death was ‘avoidable’.
But Mr Towu, 62, took the decision within hours of Paul’s arrival at the Great North Children’s Hospital in Newcastle on October 21, 2013, to operate on a defect known as an exomphalos major – rather than wait to find out more.
But an expert witness suggested the locum surgeon, who had been at the hospital for only a month, was trying to ‘prove a point’ by carrying out the surgery.
Paediatric surgeon Bruce Jeffray, who now heads the department, told the hearing he had seen just six cases of exomphalos major in his 20 years experience.
Mr Jeffray said he would have treated the condition ‘conservatively’ and would not have elected to perform emergency surgery on the new-born child.
Instead, he would have wrapped the defect in bandages and handed the baby to his mother as he was at no immediate risk, the inquest heard.
He added: ‘I think this was an avoidable death.’
Mr Jeffray described compartment syndromes as ‘disastrous’, adding: ‘You have converted a stable situation into uncontrolled chaos.’
Simon Huddart, a retired paediatric surgeon, also told the hearing: ‘A locum surgeon of one month as a consultant and performing this surgery has a feeling of trying to prove a point.
‘Seeing an operation is not the same as doing the operation, I watched my dad drive for 17 years – it doesn’t mean I could drive.’
The inquest heard his parents were not consulted ahead of the operation and Mr Towu did not discuss the decision with permanent medical colleagues ahead of the operation.
Surgery was undertaken to close a 7cm gap in his abdomen, but he quickly showed worrying symptoms of Abdominal Compartment Syndrome (ACS) due to a complication.
Expert surgeons told the four-day hearing that they would not have operated immediately, and the court heard opportunities to save his life were missed in the hours after the operation went wrong.
Police were called in and launched a manslaughter investigation on the basis Mr Towu had been grossly negligent, but no criminal action was taken against him.
Coroner Karen Dilks recorded a narrative verdict at the inquest at Newcastle Coroner’s Court on Thursday.
Paul Mitchelhill (pictured) died in his mother’s arms in 2013 following abdominal surgery
The family statement continued: ‘As a result of the failure by Mr Towu to recognise how sick Paul was, nothing was done until it was too late.
‘Paul died the day after his surgery and we came home without our son having only held him for the first time as he was dying.
‘We faced the horror of our losing our first baby boy and the trauma of him arriving home in a coffin.
‘We hope lessons have been learned as a result of Paul’s death and are pleased to note that the Trust has put measures into place to make it easier for others to challenge other colleague’s decisions and in particular locum staff.
‘We have received an immense amount of support and love from our family and friends.
‘We will now look to try to move on with our lives and our three-year-old daughter. She brings much love and happiness to our lives but we both continue to have a void left by Paul’s death.’
The parents added that they were reassured their son would get the ‘best possible care’ at Newcastle and that his future ‘looked good’.
Their statement continued: ‘This was our first baby and we were excited about his birth.
‘We knew that Paul’s condition may require him to stay in hospital for a period of time after his birth and we were prepared and expecting this.
‘Paul arrived early but safely in the Cumberland Infirmary in Carlisle on 21 October 2013 and was transferred to Newcastle within a few hours.
‘He was stable and the medical staff were happy with his condition.’
They have a nephew who was born around the same time as Paul, and they said: ‘We love him very much but he is a constant reminder of our loss.
An expert witness suggested the surgeon Emanuelle Towuaghanste was trying to ‘prove a point’ by carrying out the surgery
‘We hope lessons have been learned as a result of Paul’s death and are pleased to note that the Trust has put measures into place to make it easier for others to challenge other colleague’s decisions and in particular locum staff.’
Delivering her verdict, coroner Mrs Dilks said: ‘A locum surgeon with responsibilities for Paul’s care failed to undertake a thorough analysis of the risks and benefits of the primary closure operation.
‘He undertook the operation within the first day of life when no emergency action was indicated and without the knowledge and appropriate discussion with Paul’s parents and surgical colleagues.
‘He failed to identify abdominal colleague syndrome or give appropriate weight to the concerns expressed by the paediatric intensive team in respect of Paul’s condition.
‘He failed to undertake timely abdominal surgical decompression. These failings directly contributed to Paul’s death.’
Addressing Paul’s parents directly, she added: ‘You have had a very long and difficult time, it has been a long investigation and I hope this closure can enable you to move forward.
‘I would like to extend my very sincere personal condolences on the tragic loss of your son.’
Mrs Dilks confirmed her findings will be passed on to the General Medical Council.
Speaking after the verdict, a spokesperson for the Newcastle Upon Tyne Hospitals NHS Foundation Trust confirmed an immediate investigation was carried out after Paul’s death to ‘ensure such an event could not happen again’.
They added: ‘Newcastle Hospitals very much regrets this tragic death. This arose out of the refusal of a Locum Surgeon to respond to the professional concerns of various committed, expert and experienced medical, surgical and nursing staff.
‘We extend our sincere condolences to Paul’s parents who have been very understanding of the circumstances.’
Solicitor Lynda Reynolds from law firm Hugh James, who represented the couple, today said: ‘The family have endured a long wait for resolution of this tragic matter while GMC and police investigations have been ongoing.
‘The family have had to not only deal with these terrible events, but have also continued to have to fight for their voice to be heard since newborn Paul passed away in 2013.
‘They were initially refused Legal Aid to fund representation at the inquest and only after an appeal were they granted a 50 per cent contribution towards their legal costs.
‘The Legal Aid Agency contends it is ‘reasonable’ for the family to contribute towards their legal expenses.
‘Without specialist representation getting to the truth and understanding what went wrong and achieving some accountability for the loss of loved ones is impossible.
‘This is quite apart from the fact that public funds have been used to provide legal representation for the Newcastle upon Tyne Hospitals Trust.
‘The current circumstances create an unequal playing field, leaving the family with limited resources to fully participate in the inquest and investigation.’