Prevention of Future Deaths reports · 2013
Regulation 28 report to prevent future deaths, reference 2013-0379, written 5 Dec 2013. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Dec 2013 |
|---|---|
| Reference | 2013-0379 |
| Deceased | Desmond Statton |
| Coroner | Andrew Cox |
| Coroner area | Plymouth, Torbay & South Devon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS
This report is made under paragraph 7, Schedule 5, of the Coroners and
Justice Act 2009 and regulations 28 and 29 of the Coroners
(Investigations) Regulations 2013.
Recipients
This report is being set to:
• (cid:0)
Medical Director at Derriford Hospital, Plymouth
Coroner
I am Andrew James COX Assistant Coroner for the Coroner area of Plymouth,
Torbay and South Devon.
Coroner’s legal powers
I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act
2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
Investigation and Inquest
On 16 May 2013 an Inquest was opened into the death of Desmond Roy Statton,
who died on 26 April 2013 then aged 81. The inquest was concluded at a hearing on
3 December 2013.
The cause of death was found to be:
1a
1b
1c
2
Allergic reaction to Contrast Medium
Infective Exacerbation of Chronic Obstructive Pulmonary Disease,
Urinary Tract Infection and Coronary Artery Disease
The Conclusion of the Inquest was that Mr Statton died as the result of a known but
rare complication following the administration of contrast medium.
Circumstances of death
Mr Statton was admitted to Derriford Hospital on 10 December 2012 for a TURP. In
the Anaesthetic Room his back was sprayed with 0.5% Chlorhexidine and he was
slowly given a 240 milligram dose of intravenous Gentamicin. Mr Statton
complained that his back began to itch. He then became itchy everywhere felt sick
and vomited. He developed a tachycardia and was given adrenalin intravenously
with Hydrocortisone and Chlorpheniramine. The procedure was abandoned.
Subsequently, Mr Statton was referred to the Anaesthetic Anaphylaxis follow up
He underwent skin prick and
service where he was seen by
reported in the following terms:
intradermal tests. By letter of 3 April 2013,
“I think taking into account the history and skin test and also the severity of Mr
Statton’s respiratory problems he should avoid both Chlorhexidine and Gentamicin
for any future procedures. It is important to note for future admissions to Hospital
that Chlorhexidine is found in a number of preparations in addition to skin prep such
as Instillagel as a coating on central lines and some mouth washes. Chlorhexidine is
emerging as one of the more common causes of Anaesthetic Anaphylaxis and
although Anaphalyaxis to Gentamicin is quite rare, his skin test results were
convincingly positive”.
On 26 April 2013 Mr Statton again attended Derriford Hospital for an Out-Patient
Chest Clinic appointment. He presented in poor condition and the doctor was
concerned to exclude a P.E. He suggested a chest X-ray and CT Scan.
At approximately 12 noon blood gasses were taken from Mr Statton. It is likely that
immediately prior to the blood being taken, Mr Statton’s skin was cleaned with a
guidance issued three
solution containing Chlorhexidine notwithstanding
weeks previously.
At approximately 2.30 that afternoon Mr Statton had a cannula inserted in
preparation for the administration of Contrast Medium. Again it is likely that
immediately prior to this procedure his skin was cleaned with a solution containing
Chlorhexidine.
Mr Statton was then taken by wheelchair to undergo his CT Scan. Prior to the scan
being undertaken, the Radiographer took the deceased’s medical history and asked
whether he suffered from any severe allergies. The form records that Mr Statton
said that he did not.
The Radiographer checked on her computer system whether there were any alerts.
She found none. In evidence, it was established that the Radiographer’s computer
system did not contain information relating to alerts and allergies contained on other
computer systems available elsewhere in the Hospital. It was further established
that the Radiographer did not know of the conclusions of
investigations .
Mr Statton was administered the Contrast Medium and almost immediately suffered
a severe allergic reaction. Blood taken shortly after his collapse showed a mast cell
tryptase level of 175 (normal 2 – 14). He was said to have developed a rash at the
time of his collapse.
Mr Statton could not be resuscitated and died.
At Inquest, I found, as a matter of fact, that it was more likely than not that Mr Statton
suffered an allergic reaction to the Contrast Medium rather than the Chlorhexidine
used to clean his skin on the two occasions prior to the CT Scan.
Coroner’s concerns
During the course of the inquest the evidence revealed matters giving rise to
concern. In my opinion there is a risk that future deaths will occur unless action is
taken. In the circumstances it is my statutory duty to report to you.
The matters of concern are as follows.
1. 1.
Radiographers are not able to access information concerning alerts or
allergies contained on different computer programmes elsewhere in the
Hospital.
1. 2.
Derriford is a tertiary hospital and accepts admissions from other
hospitals elsewhere in the South West. Clinicians in Derriford are not able to
access information relating to alerts or allergies recorded on the computer
programmes in other hospitals.
1. 3.
Nursing staff are not sufficiently aware that Chlorhexidine is a growing
cause of anaphylactic reactions and that it is contained within solutions used
to sterilise the skin (and elsewhere.)
Action should be taken
In my opinion action should be taken to prevent future deaths and I believe you have
the power to take such action.
Your response
You are under a duty to respond to this report within 56 days of the date of this
report, namely by 29 January 2014. I, the Coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting
out the timetable for action. Otherwise you must explain why no action is proposed.
Copies and publication
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons namely,
,
I am also under a duty to send the Chief Coroner a copy of your response.
The Chief Coroner may publish either or both in a complete or redacted or summary
form. He may send a copy of this report to any person who he believes may find it
useful or of interest. You may make representations to me, the Coroner, at the time
of your response, about the release or the publication of your response by the Chief
Coroner.
A J COX
Assistant Coroner Plymouth, Torbay and South Devon area
Date 5 December 2013
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