A Birmingham Children's Hospital report has revealed 15 errors leading to the death of 16-year-old Ryan Senior during routine keyhole surgery, in February 2010.

What put the teenager in fatal peril though, was surgeon Dr Harish Chandran's basic mistake in selecting the wrong surgical instrument and so piercing a major vein. Internal bleeding and a fatal gas embolism developed that lead to massive blood loss and cardiac arrest.

Richard Follis, partner and national head of clinical negligence at Access Legal from Shoosmiths, is representing Ryan's family.

"This is a salutary lesson that human error can so easily kill," he said. "Systems must be effective and offer real safety rather than an illusion that all is well.

"In Ryan's case, instead of selecting a blunt instrument, the surgeon picked up a sharp one and when he used it pierced a major vein, which led, ultimately, to Ryan's death from multiple organ failure.

"It's such a simple error that could have been so easily avoided at a number of points in the process.

"What then compounded the tragic events in the operating theatre was the insensitive treatment of Ryan's mother, Sarah.

"Having been told the almost unbelievable - that her strong, fit, only child had died during a minor operation, Mrs Senior went home only 30 minutes later after being handed her son's clothes in a bag and given leaflets about bereavement. She did not find out that a major blood vessel has been torn until I found reference to the injury deep within the detail of a post mortem report months later."

The hospital's own report ultimately listed 15 errors surrounding Ryan's death, including that vital anaesthetic monitoring records had been lost.

Follis said: "After events like this, the NHS simply must embrace the family straight away and explain what is and is not known about what happened. Records should not go missing and the facts contained in later official reports should not come as a surprise to grieving relatives. 

"Whilst prevention is of course the priority, when things do go wrong the family affected need help and close support and not red tape. To compound all this, it is hard to imagine why, after an unexpected fatality that undoubtedly shocked the hospital's own staff, records should go missing.

"If the NHS did more to support victims of unintentional error we might avoid the added months - sometimes years - of heartache that families go through."

For further information regarding medical negligence claims, view our page.

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