Prevention of Future Deaths reports · 2014
Regulation 28 report to prevent future deaths, reference 2014-0259, written 5 Jun 2014. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 5 Jun 2014 |
|---|---|
| Reference | 2014-0259 |
| Deceased | Archie Hames |
| Coroner | Martin Fleming |
| Coroner area | Surrey |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 1 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
IN THE SURREY CORONER’S COURT IN THE MATTER OF: __________________________________________________________ The Inquest Touching the Death of Archie Hames A Regulation 28 Report – Action to Prevent Future Deaths __________________________________________________________ THIS REPORT IS BEING SENT TO: Surrey Community Health Secretary of State for Health 1 CORONER Martin Fleming Assistant Coroner for Surrey 2 CORONER’S LEGAL POWERS I make this report under the Coroners and Justice Act 2009 paragraph 7, schedule 5 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 30/1/12 I opened the inquest into the death of Archie Hames, who at the date his death was 3 years old. The inquest was resumed and concluded on 4/6/14. I found that the cause of death to be: 1a – Cerebral hypoxia 1b – Airway obstruction (dislodged tracheal tube) 1c – CHARGE syndrome I concluded with a narrative conclusion as follows: On 15th January 2012 Archie Hames who was born with CHARGE syndrome and reliant on assisted respiration through a tracheostomy, was found unresponsive at his home address. Upon the arrival of paramedics he was resuscitated and taken to hospital, where he was found to have suffered irreversible brain dmage and he succumbed and died of cerebral hypoxia on 19th January 2012. It is more likely than not that his tracheostomy device became dislodged when the attaching RT4052 1 Velcro strap caused wear and failure to the eyelet of the tracheostomy tube, causing it to fracture and work loose leading to cerebral oxygen starvation and death. 4 CIRCUMSTANCES OF THE DEATH 3 year old Archie Hames lived with his parents at their home address and he suffered from Charge Syndrome necessitating a tracheostomy in situ. He was at his home address on the morning of 15th January 2012 when his parents discovered that his tracheostomy tube was displaced and he was unresponsive. Upon the attendance of the paramedics he was resuscitated and taken to hospital where he was found to have suffered irreversible brain damage and he very sadly succumbed and died of cerebral hypoxia on 19th January 2012. It was subsequently found that the attaching Velcro strap to the tracheostomy tube had caused wear to its eyelet causing it to become detached causing airway obstruction and death. 5 CORONER’S CONCERNS During the inquest the following concerns arose:‐ Independent expert testing of the tracheostomy tube (model AMFNF‐49) manufactured by Arcadia Medical and its attaching Velcro strap (model Trachi‐Hold mini, TR ACC) manufactured by Kapitex Healthcare, confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of Archie’s tube The further implications of such continued use The implications of using Velcro strap attachments with other like tracheostomy tubes. I would ask that you consider give further consideration to the appropriateness of using Velcro strap attachments with tracheostomy tubes. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe that the Surrey Community Health and the Secretary of State for Health has the power to take such action. RT4052 2 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of its date; I may extend that period on request. Your response must contain details of action taken or proposed to be taken, setting out the timetable for such action. Otherwise you must explain why no action is proposed. 8 COPIES Kapitex Healthcare ‐ MHRA Children’s Community Nursing Team – Kingston Hospital ge – Medical Device Team – Welsh Government – Medical Device Team – Welsh Government – Medical Device Team – Northern Ireland – Patient Safety lead for medical devices for Scotland ‐ NHS Commissioning Board Authority – Princess of Wales Hospital Chief Coroner 9 Signed: Martin Fleming DATED this 5‐June‐2014 RT4052 3
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.
clo » 1 AAA L From the Rt Hon the Earl Howe P.C. ROR: Parliamentary Under Secretary of State for Quality (Lords) aati es Department of Health Richmond House 79 Whitehall Mr M Fleming SWiA ONS Assistant Coroner, HM Coroner’s Court Station Approach Woking i Att Qo Up Surrey ny GU22 7AP Tel: 020 7210 4850 ‘ens INF. Aewing Thank you for your letter following the inquest into the death of Archie Hames. In your report you conclude that the cause of death was cerebral hypoxia, airway obstruction (dislodged tracheal tube) and CHARGE syndrome. I was sorry to read of the events that led to Archie Hames’ death and wish to extend my sincere sympathies to his family. You raise the following matters of concern: e Independent expert testing of the tracheostomy tube (Arcadia Medical) and attaching Velcro strap (Kapitex Healthcare) confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of Archie’s tube; e The further implications of such continued use; and, e The implications of using Velcro strap attachments with other tracheostomy tubes. and ask that we consider: e the appropriateness of using Velcro strap attachments with tracheostomy tubes. We have taken advice and comment from NHS England and the Medicines, Healthcare and Regulatory Agency (MHRA). Officials at NHS England have been assured by MHRA that the type of flange damaged by Velcro in this case is no longer on the market. They have also undertaken a review of incident data reported to the National Reporting and Learning System (NRLS), to find any evidence where Velcro has damaged the flange of other like devices. Despite there being no evidence of any similar incidents, NHS England understands and accepts the advice from the testing laboratory that in laboratory conditions, it is slightly easier to break the flange with Velcro than with tapes. In addition, there are other causes and circumstances that lead to dislodgement of tracheostomy tubes as evidenced in NRLS data and in a recent report from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). NHS England has considered whether it is safe and realistic to ban the use of Velcro to secure tracheostomies. A wider review of NRLS data and clinical practice suggests there are risks as well as benefits in using either fastening system, and that a ban on Velcro might introduce new unintended risks. It might also not be considered acceptable by some patients and carers. NHS England therefore propose initiating discussions with partner agencies including NCEPOD and Patient Safety Expert Groups (PSEGs) to agree how all parties can take forward wider quality improvements to reduce the risk of tracheostomy dislodgment, including, but not limited to, the best methods of securing these devices. We would be happy to keep you updated with progress as this work goes forward. MHRA were originally made aware of the death of Archie Hames in 2012, and coordinated an investigation with the hospital and manufacturers of the involved medical devices which resulted in a report detailing their conclusions and outcomes. Further detail about this report is included in the MHRA’s full response to your Regulation 28 letter, which is provided at Annex A. MHRA will continue to survey and monitor any incidents with these products and ensure that instructions for their use result in safe use. I hope that this response is helpful and I am grateful to you for bringing the circumstances of Archie Hames’s death to my attention. Y ANNEX A MHRA Response to Regulation 28 Report from Martin Fleming Assistant Coroner for Surrey The MHRA was made aware of the death of Archie Hames on 18" January 2012 by Guys and St Thomas Foundation Trust. The MHRA coordinated an investigation with the hospital and manufacturers of the involved medical devices and produced a report for the coroner on 16" May 2012 under the reference MHRA Ref. 2012/001/018/401/003. MHRA’s investigation identified: Tracheostomy tubes-and their integrated flanges can be made from various materials for example PVC, silicone or silver and they are supplied, by tracheostomy tube manufacturers, with compatible attaching material e.g. twill tape The Arcadia Medical tracheostomy tube, in the Archie Hames case, was supplied with twill tape. A local healthcare professional decision was made not to use the twill tape supplied, but rather a Velcro holder supplied by Kapitex. Arcadia Medical investigation showed that the Velcro holder had damaged the eyelets on the tracheostomy tube’s silicone flange allowing the tube to become free from the holder and dislodge. The tracheostomy tube’s instructions for use, at the time of the incident advised to avoid contact with sharp edges, inspect condition of device at every use and cleaning, and use the twill tape supplied with the tube and tie through the flanges to secure the tube to the patient’s neck. The tracheostomy tube had been in use for 31 days which is 2 days longer than recommended by Arcadia Medical. MHRA investigation outcomes: MHRA’s incident database showed that Arcadia Medical and another manufacturer, Smiths Medical, had filed reports of damage to their tracheostomy tube’s silicone flange by a Velcro holder. Arcadia Medical and Smiths Medical agreed to clarify their instructions for use to include a specific warning not to use Velcro holders with their silicone flange tracheostomy tubes. o Arcadia Medical issued a Field Safety Notice (see attachment) to all their customers on the 7" June 2012 informing them that the instructions for use for their silicone tracheotomy tubes had been enhanced and now included the warning to not use Velcro. In 2012 Arcadia Medical developed a nylon insert to reinforce the silicone flange eyelet. From December 2012 Arcadia Medical appear to have ceased trading and no longer sell tracheostomy tubes. o Smiths Medical clarified the instructions for use of their Bivona silicone tracheostomy tube to include a specific warning against use of Velcro holders in July 2013. In May 2013, prior to the instructions being changed, brightly coloured warning inserts were placed with devices to inform healthcare professionals about changes to the instructions for use. MHRA also liaised with the manufacturer of the Velcro holder, Kapitex. On 17 March 2012 Kapitex removed the claim from their web-based product literature, that their Trachi-Hold and Velcro holder were "suitable for all brands of tube". The MHRA issued a Generic Medical Device Alert (MDA/2012/062) on 11" September 2012 to all UK Hospitals highlighting the risks and changes to instructions for use for some silicone tracheostomy tubes. A copy of MDA/2012/062 is attached. MHRA post-investigation incident surveillance: e Between May 16" 2012 and July 2™ 2014, the MHRA received 7 reports of damage to the silicone flange of the tracheostomy tube which were confirmed to be the result of use of a third party Velcro holder. The last of these reports was in April 2013. MHRA continues to monitor the situation and ensure instructions for use have clear warnings regarding the safe use of the products.
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