Our boy, 3, had just been given a new chance at life before a trainee doctor pierced an artery and caused his death
A THREE-year-old boy given a new chance at life died after a trainee doctor accidentally pierced a major artery during a routine biopsy.
Aarav Chopra suffered a “prolonged” cardiac arrest which was triggered by a build up of blood in his chest cavity and died on November 22, 2023.
Months earlier, Aarav – who suffered from serious liver disease – had undergone a liver transplant, which was meant to be a “new beginning” for him.
But his body rejected the organ so he had tests at Birmingham Children’s Hospital.
The youngster was having a routine liver biopsy when a trainee doctor pierced a major artery with a needle.
Aarav, of Wolverhampton, died as a result of serious brain damage as doctors spent nearly 30 minutes trying to resuscitate him.
An inquest heard that the bleed went “undiagnosed and untreated” during the biopsy, and Birmingham’s Senior Coroner Louise Hunt also blasted “poor planning” by staff before the procedure.
In her report, she said there was “poor” communication about the bleed Aarav suffered, “all of which hampered treatment after his collapse”.
She also noted there was “confusion around the experience of the trainee doctor performing the biopsy”.
The trainee was thought to be a year six, but it was later found out he was only in year four of his training, the inquest heard.
Aarav’s parents weren’t told a trainee would be performing the biopsy on their son.
Mrs Hunt also raised concerns that an internal meeting following Aarav’s death found “there was no immediate learning from this tragedy”.
The inquest concluded that Aarav’s death was “contributed to by neglect”.
Mrs Hunt has now issued a prevention of future deaths report, calling on Birmingham Women’s and Children’s NHS Foundation Trust to set out what action it will take.
In a joint statement, Aarav’s parents Kishore and Amrita Chopra said: “Aarav was the most courageous little boy.
“He was a happy soul with the most beautiful smile and adorable laugh. We will forever be proud of him for overcoming all the challenges he faced.
“His liver transplant was supposed to be a new beginning, a chance for him to live a better life.
“When he went into the hospital for tests, we never expected that he would never come home.
“For over 12 months, we raised concerns with the hospital about what we believed was a lack of clarity and transparency surrounding Aarav’s death.
“We only learned about the involvement of a trainee doctor in Aarav’s biopsy procedure through a Teams video recording of a meeting held by the hospital to discuss Aarav’s death in more detail.
“The hospital provided this video nine months after his death, and this crucial information was never disclosed to us earlier.
“The coroner’s inquest and subsequent findings confirmed our fears about the inadequate standard of care that Aarav received.”
Bungled care
Aarav had a condition called biliary atresia – which meant the flow of bile out of his liver was blocked.
He underwent a liver transplant on August 15, 2023 but he suffered complications and was prescribed antiplatelet medication to prevent blood clots.
After Aarav’s body started rejecting the liver, he was admitted to hospital on November 20, 2023, for a biopsy the following day.
His antiplatelet medication should have been stopped a week before the biopsy, but this wasn’t done, the inquest heard.
At the start of the procedure a trainee doctor inserted a needle through Aarav’s rib muscles, the coroner’s report said.
Medics didn’t realise at the time that the needle “did not follow the correct pathway” and pierced Aarav’s artery.
The trainee succeeded in taking a biopsy after a second attempt and a scan taken at 12.10pm at the end of the procedure.
‘Loving’ girl died after ‘catastrophic bleed’ during minor NHS procedure
Amelia Ridout, 6, died when a needle accidentally hit her artery during a biopsy.
She was having the ‘minor’ procedure after being diagnosed with a blood condition at an NHS hospital, and suffered “massive, catastrophic” internal bleeding and a cardiac arrest.
An inquest heard that a paediatric doctor saw a spurt of blood during the procedure – a warning sign that something had gone wrong.
But they were told to finish the biopsy, and shortly afterwards Amelia went into cardiac arrest.
Tragically, the six-year-old died during emergency surgery to fix the bleed.
Her father Matthew Ridout paid tribute to the little girl who showed “love” to everyone she met.
He said: “I lost my beautiful daughter Amelia ‘Millie’ tragically last year after a doctor pushed too deep during a bone marrow aspiration last year, ending Amelia’s life instantly that day.
“A day that will echo forever in my mind.”
Elizabeth Gray, area coroner for Cambridgeshire and Peterborough, has called for national guidelines to be published for this type of procedure following the fatal mistake.
Read more on Amelia’s story here.
It showed blood in Aarav’s chest cavity but this “was not identified as significant”, according to the coroner’s report.
After the procedure Aarav became agitated and medics struggled to take his blood pressure.
His parents raised concerns but it “was not appreciated that he needed further review“.
Aarav went into cardiac arrest at 1.30pm and an ultrasound at 2pm confirmed a large haemothorax – a build-up of blood in his chest- but medics failed to insert a chest drain.
The coroner’s report said: “There was no joined up discussion about how to best treat Aarav and it was unclear who was leading decision making for the complication that had occurred.”
Later that afternoon Aarav was taken back to theatre where his punctured artery was treated. Despite the surgery he died two days later.
Mrs Hunt said that had his “haemothorax been addressed at the time of the procedure Aarav would likely have been monitored and treated before the cardiac arrest”.
‘Void will never be filled’
The tot’s parents said: “The inquest has vindicated our concerns but has also deeply upset us. The hospital’s lack of accountability has completely shattered our trust.
“Aarav’s death is a loss that will stay with us forever. There is a void and emptiness in our lives that will never be filled.
“It is especially heartbreaking that Aarav will never grow up with his younger brother.
“Knowing that Aarav’s death was preventable had appropriate action been taken makes the situation even harder to accept.
“If Aarav is to leave a legacy, we hope that by sharing our story, we can urge the hospital to implement the necessary preventative actions so that no other child or family has to endure the pain and suffering that Aarav, and our family have experienced.”
Aarav’s parents have now instructed medical negligence lawyers Irwin Mitchell to investigate with a view to suing the hospital trust.
The family’s lawyer Catherine Lee said: “Aarav’s family remain devastated by his death and the events surrounding it.
“The inquest had identified extremely worrying issues in what happened.
“We continue to work with the hospital trust to conclude a separate civil case to try and come to terms with their ordeal the best they can.”
Dr Satish Rao, Chief Medical Officer at Birmingham Women’s and Children’s NHS Foundation Trust, said: “We offer our sincere condolences to Aarav’s family and loved ones.
“It’s clear from the findings of this inquest, along with those from an investigation conducted by the Trust last year, that the standard of care provided did not meet those expected and, for this, we are truly sorry.
“Following the inquest, and our own review in 2024, changes were made to our processes to improve patient care.”