Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0049, written 7 Feb 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 7 Feb 2023 |
|---|---|
| Reference | 2023-0049 |
| Deceased | Richard Kew |
| Coroner | Dianne Hocking |
| Coroner area | Leicester City and South Leicestershire |
| Category | Hospital Death (Clinical Procedures and medical management) 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.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: Department of Health and Social Care 1 CORONER I am Mrs D HOCKING, His Majesty's Assistant Coroner for the coroner area of Leicester City and South Leicestershire 2 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. 3 INVESTIGATION and INQUEST On 15 September 2022 I commenced an investigation into the death of Richard Nigel KEW aged 70. The investigation concluded at the end of the inquest on . The conclusion of the inquest was that: Mr Kew was admitted to the Glenfield Hospital Leicester and underwent a resection of small bowel endocrine tumour with extensive lymphadenectomy and resection of multiple liver metastases on the 21 July 2022. Immediately post-operatively he was admitted to the adult Intensive Care Unit. During mobilisation of Mr Kew on the 22 July there was an inadvertent omission to secure one of the central venous catheter lines with a bung. This omission allowed air entrainment into Mr Kew’s circulation. His condition deteriorated rapidly and whilst he received immediate senior medical attention, he never regained consciousness and died as a direct result of the consequences of the omission on the 05 September 2022. 4 CIRCUMSTANCES OF THE DEATH As above with a cause of death as 1a) Diffuse Hypoxic Brain Injury 1b) Air entrainment via a central venous catheter 1c) Peri-operative requirement for physiological support 1d) Ileocolic anastomosis and resection of liver metastases to treat small bowel neuroendocrine tumour and multiple liver metastases Regulation 28 – After Inquest Document Template Updated 30/07/2021 5 CORONER’S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: That whilst the University Hospitals of Leicester(UHL) have taken adequate and acceptable steps following this incident to prevent this occurrence ever happening again. In particular the UHL have now adopted a policy of having bionectors at the end of patent lines instead of relying upon a simple bung and particular training for nurses in the correct and safe way to ensure safety of the lines whilst moving patients ensuring that this aspect has become a specific competency in training. However, I am concerned that other Trusts may not have such policies and procedure in place to prevent the inadvertent error of not capping a patent line of a central venous catheter during the mobilisation of a patient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by April 04, 2023. 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. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons (wife) University Hospitals of Leicester I have also sent it to the Heath and Safety Investigation Board (HSIB) who may find it useful or of interest. I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. 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 Regulation 28 – After Inquest Document Template Updated 30/07/2021 release or the publication of your response by the Chief Coroner. 9 Dated: 07/02/2023 Mrs D HOCKING His Majesty's Assistant Coroner for Leicester City and South Leicestershire Regulation 28 – After Inquest Document Template Updated 30/07/2021
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.
From Andrew Stephenson CBE MP Minister of State for Health and Secondary Care 39 Victoria Street London SW1H 0EU 2 May 2024 Dianne Hocking Assistant Coroner Leicester City Council 115 Charles Street Leicester LE1 1FZ Dear Mrs Hocking, Thank you for your Regulation 28 report to prevent future deaths dated 7 February 2023 about the death of Richard Nigel Kew. I am replying as Minister with responsibility for Health and Secondary Care. Firstly, I would like to say how saddened I was to read of the circumstances of Mr Kews’ Death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the delay in responding to this matter and thank you for the additional time provided to the department to provide a response. The report raises concerns over the safety of Medicines and Healthcare Products. In preparing this response, Departmental officials have made enquiries with NHS England, The Medicines and Healthcare Products Regulatory Agency (MHRA) and the Health Care Safety Investigation Branch (HSIB), now the Health Services Safety Investigations Body (HSSIB) since 1 October 2023. Central venous catheters are generally considered safe when used according to guidelines, yet MHRA recognises the potential for air ingress due to inadvertent errors. In a critical incident investigated by HSIB in 2022, a tragic event unfolded when a haemodialysis catheter was left uncapped and unclamped, leading to a fatal air embolism in another patient. This incident showed the importance of addressing the risks associated with central venous catheters, particularly in haemodialysis settings where patients are vulnerable to such complications. Following this investigation, HSIB presented MHRA with a crucial safety recommendation: to amend its 2022 'Dialysis Guidance' to explicitly address the safety risk posed by unclamped haemodialysis catheters. The recommendation highlighted the necessity of updating guidelines to reflect emerging safety concerns and mitigate potential risks to patient safety. This call to action prompted MHRA to reassess and update its guidance to better address the specific challenges and risks associated with haemodialysis catheters. MHRA's guidance, initially developed in collaboration with the UK Kidney Association Kidney Patient Safety Committee serves as a vital resource for healthcare professionals and 1 patients.The guidance aims to summarise known safety issues, communicate risk mitigation measures, and provide essential information for safe and effective patient care. However, the tragic event highlighted by HSIB emphasised the need for continuous improvement and adaptation of guidelines to address evolving safety concerns and ensure optimal patient outcomes. In response to HSIB's recommendation, MHRA collaborated with key stakeholders to update the guidance, focusing specifically on the safe handling of haemodialysis catheters to prevent air embolisms. The updated guidance, published on June 21, 2023, includes detailed recommendations and protocols aimed at reducing the risk of air embolisms associated with catheters. These include measures such as proper training for staff, adherence to manufacturer guidelines, and the importance of conducting risk assessments before accessing central venous catheters. By incorporating these critical updates, MHRA aims to enhance patient safety and improve outcomes for individuals undergoing treatment. The HSIB report also notes that the Association of Anaesthetists has committed to integrating content on catheter-related air embolism into its updated 'Safe vascular access guidelines' based on the findings and safety recommendations outlined in the HSIB investigation report. When the Association of Anaesthetists update their guidance, the NHSE National Patient Safety Team will publicise this new guidance in their newsletter to all Patient Safety Specialists. I hope this response is helpful. Thank you for bringing these concerns to my attention. Yours sincerely, Rt. Hon Andrew Stephenson CBE MP Minister of State Health and Secondary Care
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.