Pictured: The grieving mother whose toddler daughter died after being left in the care of an 'inexperienced anaesthetist'
By
Andy Dolan
Last updated at 9:47 AM on 09th October 2008
A toddler who died after emergency surgery for croup had been left in the care of an inexperienced doctor, an inquest has heard.
Indya Trevelyan stopped breathing minutes after two consultants had carried out a complicated procedure to unblock her airway.
The 20-month-old had been admitted to hospital with the common childhood respiratory infection, which causes a severe cough.
Grieving mother: Sian Trevelyan clutches her daughter Indya's favourite toy as she is helped into the coroner's court this morning
But her breathing became laboured and she was given anaesthetic by staff at the Royal Alexandra Children's Hospital in Brighton.
Brighton Coroner's Court heard consultant surgeons Simon Watts and Tony McGilligan then carried out an emergency tracheotomy to help her breathe.
The child's parents Sian, 37, and Nigel, 43, from Crawley, West Sussex, were told the operation on April 15 had been a success. But staff then informed the couple their daughter was being resuscitated.
The inquest was told the consultants had used stitches to fasten down the tracheotomy tube, which had been threaded into Indya's throat to bypass her swollen airway.
They then left anaesthetist Dr David Campbell in charge after they finished - even though he had no experience of tracheotomy.
Consultants in the operating theatre had used stitches to fasten down the tracheotomy tube which had been threaded into Indya's throat
The tube became dislodged when she coughed or moved, and when Dr Campbell tried to reinsert it he ripped out the stitches.
Indya suffered a cardio-respiratory arrest which led to her death on April 18, after she was transferred to intensive care at the Evelina Children's Hospital in London.
An interim report from Brighton and Sussex University Hospitals NHS Trust concluded her death was 'preventable'.
It found the surgeons had 'no plan for the unexpected' and that 'no one took the lead' after she stopped breathing.
Consultant surgeon Tony McGilligan leaves the inquest at Brighton Coroner's Court
The report blamed 'weak communication' and stated: 'Indya's preventable death arose out of false assumptions that systems do work.'
The hospital is to review doctors' training in the light of the findings.
The inquest heard that Mr McGilligan, an ear, nose and throat specialist, did not leave instructions on how he carried out the operation or how to reinsert the breathing tube.
The consultant said: 'I didn't write what the sutures (stitches) were there for, but it was my presumption that anyone would follow why they were there.' He said the stitches had been dislodged by theatre staff trying to replace the tube.
When he realised the tube had blood round it and had become displaced, he moved Indya's windpipe and put the tube back in place.
He added: 'In hindsight I would have let everyone in the hospital know what the sutures were there for.'
Turning to Indya's parents, he said: 'I want you to know this has rocked our department to the very core. We are terribly saddened by what happened.'
Mrs Trevelyan, who had to be helped into the court by her parents, was clutching Indya's favourite cuddly toy, of the character Laa Laa from the BBC children's television programme Teletubbies.
Speaking after the first day of the inquest in August, she described her daughter's treatment as 'appalling'.
She said: 'I had dreamt of being a mum for so long. When she first looked up at me the intense love I felt was overwhelming. She was my beautiful angel.'
Croup is an infection of the voice box and the airway to the lungs. It is characterised by a seal-like, barking cough.
It affects young children aged between six months and three years. The inquest continues.
[Edit note: The Mail had incorrectly named the Consultant ENT surgeon as Ian & James McGilligan, this has been corrected to Tony McGilligan above ]
