The incident is believed to have led to his death while he was waiting for an urgent heart transplant
Nurses have described the ‘horrific sight’ when they found their patient bleeding in the middle of the night in an incident that led to his death. Luke Barnes, 34, was taken off life support at Royal Papworth Hospital in Cambridge on March 17, 2023.
This followed an “unexpected” disconnection in a pump flowing blood around his body, which is believed to have led to his death, an inquest has heard. Luke was awaiting an “urgent” heart transplant, after being diagnosed with cardiomyopathy – a chronic disease of the heart muscle – in 2018.
As he needed continuous care, he was admitted full time to Papworth in 2022. On December 8, 2022, he was fitted with a BiVad, a mechanical pump system that supports blood flow in and out of the heart muscle.
A two-day inquest, led by Coroner Elizabeth Gray, into Luke’s death began on Tuesday (January 20) at Vantage House in Huntingdon. On day one, four witnesses gave evidence.
Two staff nurses, Nurse Thomas and Nurse Kuzniarz, cared for Luke on March 16, 2023, the night the pump became disconnected. Both worked the night shift on March 16, when the tubing became disconnected.
Their roles on the night involved checking over dressing, dressing where the pumps are held and checking the whole BiVad monitor. They also check for clots with a small light through tubing, as well as around the connections and pumps.
Mr Kuzniarz said that throughout the night there was “nothing unusual” happening with Luke. He said that around 3am Luke was “awake but then went back to sleep”, and at 4am he checked his BiVad machine, which was “normal”. At around 5.40am, the court heard from both nurses that they were together, but “not far away” from Luke.
From Luke, Ms Thomas heard a “sigh”, while Mr Kuzniarz heard a “gasp”. Ms Thomas told the court she went over to Luke and saw “blood”.
She said she pulled back Luke’s blanket and saw a “pool of blood”. She recounted that she saw his cannula was disconnected and because she “saw no blood in the cannula”, she reinserted it.
Mr Kuzniarz confirmed he also saw blood on Luke’s bedding. Both nurses said the doctors were called “quickly” and they “proceeded with resuscitation”.
Family solicitor Mr Thomas wanted clarification from Ms Thomas on how they monitor the BiVad machine. Ms Thomas said nurses can see the machine, which measures blood flow rate and that Luke’s was “stable” throughout the night.
Mr Kuzniarz was also questioned by Mr Thomas, and he was asked for a description of what he saw. Mr Kuzniarz said there was a “severe loss of blood” and it was a “horrific sight”.
Dr Steven Pettit, consultant cardiologist at Royal Papworth, gave evidence and demonstrated how a BiVad works to the court. He also spoke of the care Luke got at Papworth and his reasoning for the possible disconnection of tubing in the BiVad.
Dr Pettit said Luke was placed on a waiting list for a heart transplant in March 2022 and the waiting time for this list can be “several years”. He was admitted in November 2022 with a “worsening heart flow and kidney function”. Dr Pettit said Luke was treated with diuretics and other medications to “increase blood flow around the body”.
The court heard Luke was moved to a more urgent transplant list, and referred to the critical care team in December 2022. On December 8, 2022, Luke underwent emergency surgery to have a BiVad fitted.
Dr Pettit told the court this is a “temporary mechanical support” to “circulate blood flow around the body”. With the BiVad fitted, Dr Pettit said Luke’s condition “improved sufficiently” and he was placed on the highest urgent transplant list.
A circuit change for the BiVad takes place every four to six weeks, with Luke’s first change taking place on January 19, 2023. Another change took place on March 14, 2023, two days before the “unexpected disconnection”.
In questioning, Coroner Gray asked Dr Pettit when an alarm would sound to alert of the fault. Dr Pettit said the alarm would have not been expected to sound immediately, “until blood flow exceeded” through the pipe. Dr Pettit added: “Instead of being pumped into Luke, it was leaking from the system into his bed sheets”.
The doctor explained that there were two possibilities of where it could have disconnected. The two possibilities were at the “interference between the internal and external tubing”, or between the cannula and tubing. Dr Pettit said it was his “understanding” it disconnected at the cannula connection.
The court later heard that this connection is not changed in the BiVad circuit changes. Dr Pettit added it takes “some force” to replace the new tubing, and when it’s changed it has to be “slick and fast”. The doctor compared the change to a “Formula One tyre change”.
Coroner Gray then questioned Dr Pettit about possible blood clots, and if it would lead to an increase in pressure along the tubing, which could have led to a disconnection. It was confirmed clots would not lead to an increase in pressure to cause the disconnection.
Dr Pettit added that he was not present when the tubing became disconnected, but added that it would have been a “horrifying thing to have discovered”. He said: “It would be human nature in that situation to immediately shout for help.”
Aimee Blunt, a member of the Cambridge Perfusion team, spoke of her role in preparing circuit changes for BiVad equipment, how the change is done and what was done with Luke’s change on March 14.
Coroner Gray questioned Ms Blunt on disposal of the old tubing, and Ms Blunt confirmed this was disposed of in “biohazard waste”. Ms Blunt reiterated that the pump where it is believed the tubing became disconnected – the connection between the cannula and tubing – is the part that is not changed. Ms Blunt told the court this part is “essentially glued” together.
Family solicitor Mr Thomas questioned Ms Blunt if disposed of circuits are checked after. Ms Blunt said if there were “problems” then the old circuits would be “put into quarantine”.
After witnesses spoke, Coroner Gray read out a report carried out by Royal Papworth. One doctor said this was a “rare, but known event”. In summary, it confirmed an “unexplained disconnection” in the system led to a “massive hemorrhage”. Changes were made after this event, including adding cable ties to the tubing to secure it more. “Additional vigilance” from teams changing the circuit was also recommended, and to ensure that the “tubing is pushed in fully”. These recommendations are currently in place.
The inquest continues today (Wednesday, January 21).
