An ‘adorable’ three-year-old boy died after a trainee doctor accidentally pierced a major artery during a routine procedure.
Aarav Chopra suffered a prolonged cardiac arrest triggered by a buildup of blood in his chest cavity and died on November 22, 2023.
The youngster was having a routine liver biopsy – where a small tissue sample is taken from the body for examination – when a trainee doctor pierced an artery with a needle.
Months earlier Aarav had undergone a liver transplant but his body was rejecting the organ, so he was undergoing tests at Birmingham Children’s Hospital.
Aarav, from Wolverhampton, died as a result of serious brain damage after doctors spent nearly 30 minutes trying to resuscitate him.
His condition went ‘undiagnosed and untreated’ during the procedure, an inquest heard.
Birmingham’s Senior Coroner Louise Hunt condemned ‘poor planning’ by staff before the biopsy.
She said there was poor communication about the bleed Aarav suffered, ‘all of which hampered treatment after his collapse.’
Aarav Chopra (pictured) died after a major artery was punctured during a routine biopsy
There was also ‘confusion around the experience of the trainee doctor performing the biopsy.’
The trainee was thought to be in his sixth year but was only in year four of his medical training.
Aarav’s parents were unaware that a trainee would be performing the biopsy on their son.
But an internal meeting following Aarav’s death found ‘there was no immediate learning from this tragedy.’
However, the inquest concluded that Aarav’s death was ‘contributed to by neglect.’
Ms Hunt has now issued a prevention of future deaths report calling on Birmingham Women’s and Children’s NHS Foundation Trust to outline 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.
The parents of the ‘adorable’ three-year-old ate taking legal action against the hospital 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.
‘His liver transplant was supposed to be a new beginning, a chance for him to live a better life.’
Aarav had a condition called biliary atresia, meaning bile flow out of his liver was blocked.
He underwent a liver transplant in August, 2023, but suffered complications and was prescribed antiplatelet medication to prevent blood clots.
‘When he went into the hospital for tests, we never expected that he would never come home,’ his parents said.
After Aarav’s body started rejecting the liver, he was admitted to hospital on November 20, 2023, for a biopsy the following day.
But no consideration was given to his antiplatelet medication which should have been stopped a week before the procedure.
Mr and Mrs Chopra said: ‘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.
Birmingham Children’s Hospital, where Aarav died in November 2023
‘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.’
At the start of the procedure a trainee doctor 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 then 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.’
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’.
The Trust’s Chief Medical Officer Dr Satish Rao admitted the standard of care was inadequate
He went into cardiac arrest at 1.30pm and an ultrasound at 2pm confirmed a large haemothorax – a build-up of blood – 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. 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.’
Aarav’s parents said: ‘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.
‘It is 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.
Aarav’s biopsy was carried out by a fourth year trainee, thought to be in his sixth year due to ‘poor communication’ (Pictured: Birmingham Children’s Hospital)
‘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.’
Mr and Mrs Chopra 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, the Trust’s Chief Medical Officer, admitted the standard of care provided did not meet those expected.
‘For this, we are truly sorry,’ he said.
‘We offer our sincere condolences to Aarav’s family and loved ones.
‘Following the inquest, and our own review in 2024, changes were made to our processes to improve patient care.’
