A heart surgeon reportedly turned down the chance to train on a robot he used in an operation in which the patient later died.
Stephen Pettitt, 69, suffered multiple organ failure and died days after the procedure at the Freeman Hospital in Newcastle in March 2015.
Pettitt's heart valve operation was assisted by a robot and it was the first of its type at the trust.
On 4 November a coroner was told that the lead surgeon, Sukumaran Nair, reportedly admitted to a colleague that he could undergo more training on the sophisticated system. The robotics experts who were assisting the surgical team left part-way through the operation without informing staff.
Although robots such as the Da Vinci system are used to enable accurate key-hole surgery, the surgery in 2015, which was done to repair a mitral valve, damaged the interatrial septum, forcing the team to open Pettitt’s chest to repair the tear, reports indicate.
"By that time the operation had been going on for a considerable period of time," pathologist Nigel Cooper was quoted as saying by the Telegraph. “By the end of the surgery, the heart was functioning very poorly."
Although attempts were made to improve the heart function, Pettitt's organs began to shut down and he could not recover.
After the patient died, Nair telephoned Paul Renforth, a co-ordinator in the use of robotics at the Freeman Hospital, to say "the procedure had not gone as planned."
Renforth added: "(He said) possibly he could have done some more dry-run training."
The co-ordinator also said that the atmosphere in the operating room was tense.