Prevention of Future Deaths reports · 2016
Regulation 28 report to prevent future deaths, reference 2016-0050, written 15 Feb 2016. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 15 Feb 2016 |
|---|---|
| Reference | 2016-0050 |
| Deceased | Peter Tye |
| Coroner | Ian Arrow |
| Coroner area | Plymouth, Torbay and South Devon |
| 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.
IAN MICHAEL ARROW Senior Coroner for Plymouth, Torbay and South Devon REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: Secretary of State for Health Rt. Hon Jeremy Hunt MP. Department of Health, Richmond House, 79 Whitehall London Sw1A 2NS CORONER lam IAN MICHAEL ARROW, Senior Coroner for Plymouth, Torbay and South Devon, | Derriford Park, Derriford Business Park, Plymouth PL6 5QZ 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. http://www. legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7 http://www. legisiation.gov.uk/uksi/2013/1629/part/7/made INVESTIGATION and INQUEST On 17/09/2015 | commenced an investigation into the death of Peter Charles Tye aged 73 years. The investigation concluded at the end of the inquest on 15 February 2016. The conclusion of the inquest was NARRATIVE The deceased was admitted to Derriford Hospital, Plymouth on 2 September 2015 and despite treatment sadly died on 10 September 2015. The medical cause of death was 1 (a) Gram Negative Septicaemia with Pneumonia and Diffuse Alveolar Damage Cerebral Infarct following Cannulation of the Cartoid Artery CIRCUMSTANCES OF THE DEATH Mr Tye was admitted to hospital on the 3rd September with pneumonia / respiratory failure and unexplained weight loss. On the 4th September, whilst on ITU there was a recognised complication when a central line was inserted into his carotid artery instead of his vein. After this he remained stable for 2 days but then deteriorated with gram negative sepsis. His condition did not improve and he sadly died. 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. — At an Inquest touching the death of Peter Charles Tye, | received evidence from that improvements at Derriford Hospital had been made following the events during which a central venous line was misplaced into an artery. A Root Cause Analysis has indicated various improvements which can be made. These improvements concern both the insertion and the removal of central venous lines. Adoption of those processes is likely to reduce the numbers of deaths from misplaced lines. Details have been shared with the Faculty of Intensive Care Medicine. be reduced by the promulgation of this good practice. In my view deaths might 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 =| Fax 01752 313297 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and | believe you, The Secretary of State for Health have the power to take such action by promulgating the now developed best practice. YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 11 April 2016. 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 Chief Executive, Derriford Hospital, President of the Faculty of Intensivists an lam 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. Dated 15 February 2016 Senior Coroner for Plym@uth, Torbay and South Devon 3 The Crescent, Plymouth, PL1 3AB Tel 01752 204 636 | Fax 01752 313297
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.
Mr. Ian Arrow HM Senior Coroner, Plymouth hmcoroner@plymouth.gov.uk Dear Mr. Arrow, 8th April 2016 In response to Regulation 28 report relating to an inquest touching on the death of Peter Tye Thank you for your letter involving this unfortunate case. The report has been discussed by the Faculty’s Board and Professional Standards Committee. We recognise that Mr. Tye’s stroke was most likely caused by the misplacement and removal of the line and, as indicated in the report, acknowledge that the hospital has learnt from this case and has implemented changes to reduce the risk of the incident being repeated in the future. The ICM training programme requires trainees to understand and recognise complications from line insertions however, the number of procedures required for sign off is not mandated nor do we believe that this type of complication would be prevented if this were the case. The spiral nature of our curriculum requires the trainee to demonstrate increasing levels of competence for this procedure resulting in a competence which would indicate that the trainee was capable of independent level practice. This is assessed by means of workplace based assessments, performed by consultant trainers who would also assess the trainee's knowledge of the indications for and complications of the procedure. Trainees in ICM are also expected to have an understanding of the process of reporting of critical incidents, serious untoward incidents and root cause analysis and are expected to attend mortality and morbidity meetings throughout their training. As such, the ability to learn from incidents of patient harm must be demonstrated. As acknowledged in the report the evidence base for dealing with inadvertent carotid artery puncture is not clear, but again we would expect this to be something that is discussed in order to demonstrate competence at this procedure. The authors of the report recognise that in Mr. Tye’s case there was little they could do to mitigate the complication once it had occurred due to the instability of the patient. This is unfortunately the nature of intensive care medicine and when patients who are critically unwell develop iatrogenic complications of any kind, management of the complication will have to be considered on an individual patient basis. The FICM and ICS Joint Standards Committee are currently discussing how to monitor incident reports and publicise the lessons learnt as a result of such incidents. Mr. Tye’s case will be discussed at the next meeting where a mechanism for cascading this information will be agreed. Yours sincerely, Dean of the Faculty of Intensive Care Medicine
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