STATEMENT: INDEPENDENT REPORT INTO THE INCIDENT THAT LED TO THE
DEATH OF ABBIE HATTAM
University Hospitals Bristol NHS Foundation Trust has published
an independent report of the root cause analysis it commissioned
into the circumstances that led to the death of Abbie Hattam.
Abbie, who was five months old, died on 27 May 2005 following
complex, high-risk cardiac surgery on 25 May 2005. The Coroner
ordered a police investigation into Abbie's death but no criminal
prosecution was pursued. The Coroner's Inquest was held and
concluded on 16 February 2007. The Inquest reached a verdict of
'unlawful killing' and found that during the operation Abbie
received an overdose of calcium that resulted in irreversible brain
damage and subsequent death the following day.
UHBristol put safeguards into place immediately after Abbie's
death to minimise the likelihood of any similar incidents happening
again. As part of the 'safeguarding' process UHBristol undertook a
root cause analysis. However, this investigation could not start
until the police investigation had finished.
The root cause analysis was led by Mark Gritten, an experienced
NHS senior professional who is independent of the Trust. Mr Gritten
was supported by independent expert witnesses. His report concludes
that this was a unique incident
