Parents And Medical Negligence Lawyers Call for Improved Care as Inquest Rules Boy’s Death “Contributed To By Neglect”

A coroner has demanded action after medics did not realise they had pierced a three-year-old boy’s artery during surgery, triggering a fatal cardiac arrest.

Aarav Chopra’s cardiac arrest was caused by a build-up of blood in his chest cavity which went “undiagnosed and untreated” during a liver biopsy performed by a trainee doctor at Birmingham Children’s Hospital, a coroner ruled.

Aarav, of, Wolverhampton, died as a result of serious brain damage suffered as doctors spent nearly 30 minutes trying to resuscitate him.

There had been “poor planning” before the procedure when there was no consideration to stopping anti-blood clotting medication that Aarav was on. There was “poor” communication about the bleed Aarav suffered, “all of which hampered treatment after his collapse,” a coroner’s report said.

Medical negligence lawyers secure answers over Aarav's care at Birmingham Children's Hospital 

An inquest in which the family were represented by expert medical negligence lawyers at Irwin Mitchell concluded that Aarav’s death was “contributed to by neglect.”

Senior Coroner Louise 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. It comes after the coroner raised several concerns including:

• Confusion around the experience of the trainee doctor performing the biopsy who was thought to be a year six trainee but was a year four trainee.

• There was no mechanism to evidence trainees’ experience and competence when they travel to different hospital trusts as part of their training.

• Aarav’s parents were unaware a trainee would be performing the biopsy and there was no way to obtain consent when a trainee will be carrying out the procedure.

• An internal hospital morbidity and mortality meeting held after Aarav’s death to discuss his care was “inadequate”. Mrs Hunt was concerned that the meeting found “there was no immediate learning from this tragedy.”

Family and legal expert call on Trust to learn lessons from Aarav's care issues 

Aarav’s parents, Kishore and Amrita Chopra have now joined their legal team at Irwin Mitchell in welcoming the coroner’s report and calling on the Trust to ensure it learns lessons.

Catherine Lee, the expert medical negligence lawyer at Irwin Mitchell representing Aarav’s family, said: “Aarav’s family remain devastated by his death and the events surrounding it. Understandably they had a number of questions and concerns about their son’s care and were particularly concerned at the Hospital Trust’s own findings.

“While nothing can make up for what they’ve been through, we’re pleased that we’ve been able to secure the answers Aarav’s loved ones deserve.

“The inquest had identified extremely worrying issues in what happened. We call on the Trust to reflect on how it conducts internal morbidity and mortality meetings and the coroner’s findings to ensure the highest patient safety standards are upheld.

“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.”

Aarav Chopra's story

Due to an underlying condition called biliary atresia – which meant bile flow out of Aarav’s liver was blocked - he underwent a liver transplant on 15 August, 2023. However, he suffered complications and was prescribed antiplatelet medication to prevent blood clots. 

Following his transplant Aarav exhibited acute rejection. He was admitted to Birmingham Children’s Hospital on 20 November, 2023, for tests including a biopsy, the following day.

However, no consideration had been given to stopping his antiplatelet therapy which should have been stopped a week before the planned procedure, the coroner’s report said. Medics involved in the procedure were unaware he was on antiplatelet medication.

A trainee doctor was supervised by a consultant interventional radiologist for the biopsy. He inserted a needle through Aarav’s rib muscles. However, it could not be seen on imaging and “it was not appreciated at the time that the needle did not follow the correct pathway,” the coroner’s report said.

A second, successful attempt at a biopsy was made.

A scan taken at 12.10pm at the end of the procedure identified blood in Aarav’s chest cavity but it “was not identified as significant.” This finding was not treated or communicated to other staff caring for Aarav.

The coroner’s report said that the operation notes did not record that two biopsy attempts were made nor that there were concerns about a bleed.

After Aarav's discharge from recovery, his parents raised concerns as he became agitated, and medics struggled to take his blood pressure. However, it “was not appreciated that he needed further review”. 

Aarav went into cardiac arrest at 1:30 pm. An ultrasound at 2pm confirmed a large haemothorax, but no chest drain was inserted.

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. It was confirmed he had suffered brain damage during his “prolonged” cardiac arrest.

He died on 22 November, 2023.

Mrs Hunt found had his “haemothorax been addressed at the time of the procedure Aarav would likely have been monitored and treated before the cardiac arrest.” 

Immediately following Aarav’s death, Birmingham Children’s Hospital identified no care delivery issues contributing to his passing. 

Consequently, Aarav’s parents demanded an independent external clinical review, which was conducted by medics from King’s College Hospital in London. The external clinical report identified 34 shortfalls and 32 recommendations highlighting areas of sub-optimal care.

Parents' tribute to courageous little boy as they campaign for improved patient safety

In a joint statement, Aarav’s parents 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 new 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. 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.”

Find out more about Irwin Mitchell's expertise in supporting families affected by care issues at our dedicated medical negligence section. Alternatively, to speak to an expert contact us or call 0370 1500 100.