Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0171, written 15 Apr 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Apr 2014 |
|---|---|
| Reference | 2014-0171 |
| Deceased | Desiree Falvo |
| Coroner | Fiona Wilcox |
| Coroner area | London Inner (West) |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text recovered by OCR from a scanned PDF. OCR is imperfect: check anything you rely on against the source PDF. Reproduced verbatim, including the scan's own layout.
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: NHS England PO Box 16738 Redditch B97 9PT 1 CORONER | am Dr Fiona Wilcox, Senior Coroner, for the coroner area of Inner West London 2 | CORONER’S LEGAL POWERS | 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. 3 | INVESTIGATION and INQUEST On Saturday 24" August 2013 | commenced an investigation into the death of Ms Desiree Harmony Falvo, aged 35 years. The investigation concluded at the end of the inquest on 26" March 2014. The conclusion of the inquest was: Medical Cause of Death 1 (a) Hypoxic Brain Injury (b) Cardiorespiratory Arrest (c) Upper airway tract obstruction (treated August 2013). How, when and where and in what circumstances the deceased came by her death: Ms Falvo had congenital laryngeal stridor due to immobile vocal cords which required multiple surgical procedures. On 20/8/2013 she had a relatively minor procedure to assess her suitability for reconstructive surgery at Charring Cross Hospital. This appeared to go well. Post operatively she did not feel right in herself, however was discharged objectively fit at approximately 13:30 on 22/8/2013. That evening she developed difficulty in breathing over a couple of hours, vomited then deteriorated rapidly. LAS was called and she was transferred to St George’s Hospital. On arrival she was in extremis. The treating doctors had difficulty in securing her airway due to obstruction around the vocal cord area, scarring in her neck and her body habitus, during which she arrested. By the time the ENT Registrar had arrived and completed a tracheostomy, she had suffered hypoxic brain injury. She died at 05:58 on ITU at St George’s Hospital. The cause deterioration is unknown. Conclusion of the Coroner as to the death Narrative- see above. CIRCUMSTANCES OF THE DEATH It was clear from the evidence taken during the inquest that an expert team was attempting to resuscitate Ms Falvo in very difficult circumstances. A paediatric intensivist had almost got the tracheostomy in place just as the ENT Registrar had arrived and took over the surgical tracheostomy insertion. However a recurrent theme of the evidence was that the procedure required to secure Ms Falvo’s airway was the expertise of the non resident ENT surgeon. | understand from discussion with the experts called to give evidence, that there are insufficient ENT Registrars to be resident in all A&E Departments and that whilst those working in A&E and expected to manage airways are trained in emergency surgical tracheostomy techniques, many of these clinicians feel uneasy and lack the confidence to perform such procedures. 4 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) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy, (2) That the training planned and provided to those expected to manage and secure airways including the use as appropriate of surgical tracheotomy, is reviewed and upgraded such that those clinicians have both the skills and confidence to perform such procedures in an emergency situation. ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you [AND/OR your organisation] 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 11" June 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 | have sent a copy of my report to the Chief Coroner and to the following Interested Persons : | have also sent it to the following persons or organisations who may find it useful or of coum ENT Surgeon, Charing Cross Hospital, Fulham Palace Road, London. —_ in Emergency Medicine, St George’s Hospital, Blackshaw Road, London. SW17 OQT. St George’s Hospital, Blackshaw Road, London. SW17 OQT. 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. 15™ April 2014 Dr Fiona Wilcox, HM Senior Coroner, Inner West London, Westminster Coroner’s Court, 65, Horseferry Road, London. SW1P 2ED.
1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
NHS England London Region Southside 105 Victoria Street London SW1E 6QT 2 June 2014 PRIVATE AND CONFIDENTIAL Dr Fiona Wilcox, HM Senior Coroner Inner North West London Westminster Coroner's Court 65 Horseferry Road London, SW1P 2ED Dear Dr Wilcox, Thank you for raising the issues arisi i igation and inquest into the death of Ms Falvo. | am responding on behalf of ) Medical Director for London and || FY You raised two matters of concern:- 4 (1) The A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency tracheotomy. (2) That the training planned and provided to those expected to Manage and secure airways including the use as appropriate of surgical tracheotomy, is reviewed and upgraded such that those clinicians have both the skills and confidence to perform such Procedures in an emergency situation. First let me express regret at this sad death and | share your wish that lessens can be learnt to reduce the risks of such a tragedy recurring. There are insufficient experienced ENT Surgeons to provide immediately available resident cover in all A&E departments at all times, and to do so would be impractical. Acute Trusts responsible for the provision of A&E services are expected to recognise and manage this risk by ensuring that general training is available to the initial receiving staff in A&E, and that specialist expertise can be accessed in a timely way. A&E senior staff are trained as part of Advanced Trauma Life Support (ATLS) in both tracheotomies and needle crichothyroidotomy. This is repeated at least every four years to ensure skills and confidence are maintained, Across London there has been a review of Emergency Departments and the availability of senior staff with these skills as part of a wider review of Quality Standards in Acute Trusts. It is clear that provision has varied, and a standard has been agreed so that Major Trauma units have consultants on site 24/7 and all A&Es will have increased consultant presence over 16 hours with senior training doctors (ST4s) on site and available for the other time. This is a substantial challenge as there is a shortage of A&E doctors, but already many Trusts have made strides to meet these standards and this has also been a drive behind the reconfiguration of some A&Es. The Urgent and Emergency Care review, currently being led vy TE . expected to lead to the development and designation of Emergency Centres and Major Emergency Centres, and ensuring that clear standards and robust plans are in place to deal with this and similar emergencies will be an important component of this development. The first stage report was published in November 2013 and further information is expected over the summer. Whilst the circumstances are very unusual, we know that an emergency surgical airway will be required from time to time (perhaps once every 3-5 years in a typical A&E Department). Training in this procedure is already given to all those who provide advanced airway interventions in an emergency. This includes doctors specialising in A&E, anaesthesia and intensive care. Relevant guidelines are disseminated by the Difficult Airway Society and are widely taught and followed, with practical training using manikins and animal models (for example sheep larynx), during "Advanced Life Support" courses. Because this is a very rarely performed procedure it is approached with trepidation by some. However, figures from the 4th National Airway Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, completed in 2011 a. behalf of the Fourth National Audit Project. Royal College of Anaest etists, London, March 2011] indicate that the success rate is generally very good when a surgical approach is used, as in this case. Itis clear that Ms Falvo presented more substantial challenges than other patients, with scarring and obstruction that made intervention much more complex than in is expected in these already very uncommon occurrences. Nonetheless the review and implementation of increased senior doctor in A&Es and the National Review of Urgent and Emergency Care will substantially reduce the risks of this tragedy recurring. Yours sincerel Deputy Regional Medical Director NHS England (London) National Clinical Director for acute episodes of care National Medical Director
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