Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0286, written 29 Jun 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Jun 2023 |
|---|---|
| Reference | 2023-0286 |
| Deceased | Clinton Fear |
| Coroner | Simon Fox |
| Coroner area | Avon |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Organisation named | North Bristol NHS Trust |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
M. E. Voisin
His Majesty’s Senior Coroner
Area of Avon
29 June 2023
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
UK Health Security Agency
1
CORONER
I am Dr Simon Fox KC, Assistant Coroner for Area of Avon
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.
http://www.legislation.gov.uk/ukpga/2009/25/schedule/5/paragraph/7
http://www.legislation.gov.uk/uksi/2013/1629/part/7/made
3
INVESTIGATION and INQUEST
On 26th July 2022 an investigation into the death of Mr. Clinton Peter Fear was commenced.
The investigation concluded at the end of the inquest 29th June 2023. The conclusion of the
inquest was -
Mr Fear died from a Mycobacterium Chimaera infection acquired from a Liva Nova heater
cooler unit during open heart surgery.
The cause of death was –
1a) Hospital acquired pneumonia;
b) Disseminated Mycobacterium Chimaera infection following a composite aortic root
replacement (November 2012).
CIRCUMSTANCES OF THE DEATH
4
Mr Fear underwent cardiac valve replacement surgery in November 2012 and during surgery he
contracted Mycobacterium Chimaera infection from a Liva Nova heater cooler unit (part of the
heart bypass machine).
He developed symptoms of Mycobacterium Chimaera in the form of night sweats in
2017/2018, was diagnosed and started on treatment in October 2019, suffered a protracted
disabling illness for 3 years and died from the infection in July 2022.
The Coroner's Court Old Weston Road Flax Bourton BS48 1UL
He was not notified of the risk of Mycobacterium Chimaera infection from the operation when
this risk became known in 2015 because his operation was before January 2013 – the date from
which patients were then considered to be at risk and adopted in guidance from Public Health
England.
Mr Fear contracted his Mycobacterium Chimaera infection at surgery before January 2013 and
other cases have been reported from surgery dating back to at least 2008.
5
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. There is an inconsistency between –
Previous Public Health England and current NHS guidance only to notify patients
undergoing surgery from January 2013 of the risk of Mycobacterium Chimaera infection
And
Evidence of patients contracting Mycobacterium Chimaera infection from surgery
substantially earlier than January 2013 (at least as far back as 2008);
2. There appears to be no current basis for maintaining a start date of surgery in January
2013 for patient risk notification when there is evidence of infection substantially
earlier than this date;
3. Patients who have contracted Mycobacterium Chimaera infection from surgery before
January 2013 may be suffering a delay in diagnosis and consequent harm as a result of
a lack of notification due to the existing guidelines.
The Coroner's Court Old Weston Road Flax Bourton BS48 1UL
6
ACTION SHOULD BE TAKEN
In my opinion action should be taken to prevent future deaths and I believe you 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 31st August 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
- Deceased’s family;
- University Hospital Bristol and Weston NHS Trust.
I have also sent it to North Bristol NHS Trust who may find it useful or of interest.
I 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.
9
29/06/2023
Dr. S. Fox KC
H. M. Assistant Coroner
The Coroner's Court Old Weston Road Flax Bourton BS48 1UL
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