Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2015-0253, written 2 Jul 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 2 Jul 2015 |
|---|---|
| Reference | 2015-0253 |
| Deceased | Gail Prentice |
| Coroner | Sarah-Jane Richards |
| Coroner area | Powys, Bridgend and Glamorgan Valleys |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
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.
ANNEX A
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
NOTE: This form is to be used after an inquest.
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1. Chief Coroner
2. Minister for Health, National Assembly for Wales
3. Chief Executive, Cwm Taf University Health Board
4. EE Cwm Taf University Health Board Investigator
5.
CORONER
| am Dr. Sarah-Jane Richards, Assistant Coroner, for the coroner area of Powys,
Bridgend and Glamorgan Valleys
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.
INVESTIGATION and INQUEST
On the 4" March, 2015 | commenced an investigation into the death of Mrs. Gail
Prentice. The investigation concluded at the end of the inquest on the 47" April, 2015.
The conclusion of the inquest was ‘Complications of a surgical procedure on a
background of multiple and severe health conditions’.
CIRCUMSTANCES OF THE DEATH
Mrs. Prentice, 46 years, had suffered multiple and serious ill health events in life
including dialysis dependent diabetes, breast cancer with bilateral mastectomy,
thyroidectomy, toe amputations, cardiac arrest and renal failure. She had been admitted
to the Royal Glamorgan Hospital falling a fall and had suffered a PEA arrest. She had
been ventilated fully and a previous attempt to extubate had failed. It was considered
that a tracheostomy would assist Mrs. Prentice being weaned off the ventilator but it was
not an essential, life sustaining procedure.
The percutaneous dilation tracheostomy was performed in the [TU and commenced by
as ENT cia under the supervision of Z|) associate
specialist ENT surgeon. had previously performed only two percutaneous
tracheostomies. Complications arose when the patient bled profusely after the insertion
of the second dilator by [EE The bleed could not be stemmed and Mrs. Prentice
died in consequence.
The post-mortem cause of death was given as - 1a massive blood loss; and 1b
transection of the brachiocephalic artery during attempted tracheostomy formation.
Witness evidence confirmed that in patients requiring tracheostomy and where there had
been previous neck surgery, ultrasound should have been undertaken to identify internal
structures within the altered neck anatomy and to determine the site of entry. At the
very least, the tracheal rings should have been counted in order to avoid puncturing the
artery on insertion. The usual placement is between the 2™ and 3™ tracheal rings
whereas in Mrs. Prentice, the site was low down the neck at the level of the 9" and 13”
rings.
The outcome of the Cwm Taf University Health Board's investigation was submitted to
the Coroner prior to the inquest. In this report, the ‘lessons learned’ cited that
¢ apatient's previous medical history should be noted prior to tracheostomy;
e inthe event of previous neck surgery having been undertaken, a full ultrasound
should be completed; and
© where previous neck surgery had been performed any new tracheostomy should
be inserted in theatre and not in the ITU.
The Health Board acknowledged its Guidelines for Tracheostomies did not address the
scenario of altered neck anatomy post previous neck surgeryand this was an omission
which it was seeking to address from these ‘lessons learned’.
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) The requirement for surgeons to acknowledge having read the Health Board’s
Hospital Guidelines and those of other bodies e.g. NICE Guidelines
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and | believe you and your
organisation have the power to take such action in the area of:
> Ensuring the Hospital's Tracheostomy Guidelines take into account the checks
tequired when there has been previous neck surgery;
> Percutaneous tracheostomies should be performed in the theatre environment
rather than in the ITU; and
Feedback to Health Boards that ENT surgeons have read its Guidelines.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report,
namely by 18" September, 2015. |, 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, Mr. Mark Drakeford, Minister of
Health, National Assent for Wales; Mrs. Allison Williams, Chief Executive, Cwm Taf
University Health Board; Cwm Taf University Health Board Investigator,
and OSE —E—————
| am also under a duty to send the Chief Coroner a copy of your response.
r both in a complete or redacted or summary
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.
Dr. Sarah-Jane Richards
HM Assistant Coroner
Powys, Bridgend & Glamo!
2" July 2015
gan Valleys
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