Prevention of Future Deaths reports · 2024
Regulation 28 report to prevent future deaths, reference 2024-0421, written 30 Jul 2024. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 30 Jul 2024 |
|---|---|
| Reference | 2024-0421 |
| Deceased | Derryck Crocker |
| Coroner | Samantha Goward |
| Coroner area | Norfolk |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 8 |
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: The President, The Royal College of Emergency Medicine - The President, The The Royal Society of Medicine - The President, The Royal College of Physicians - The President, The Royal College of Surgeons - The President, The Royal College of Anaesthetists - 1 CORONER I am Samantha GOWARD, Area Coroner for the coroner area of Norfolk 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 12 May 2023 I commenced an investigation into the death of Derryck Lynn CROCKER aged 77. The investigation concluded at the end of the inquest on 30 July 2024. The medical cause of death was: 1a) 1b) 1c) 2) Iatrogenic Cerebral Gas Embolism Lung biopsy under computed tomography (CT) guidance Lung lesion, suspected cancer The conclusion of the inquest was: Died due to the delayed recognition and treatment of a rare, but recognised complication of a lung biopsy. 4 CIRCUMSTANCES OF THE DEATH On 3 May 2023 Derryck Crocker attended hospital for a lung biopsy after previous investigations had shown a suspicious mass. As part of the consent process the risks identified were bleeding/haemoptysis, infection, pneumonia, pneumothorax, insertion of chest drain & inadequate sampling. Air embolism was not a risk consented for at that time. The procedure started at 13.00 hours & biopsies were taken at 13.18 hours. Immediately after the samples were taken, Mr Crocker developed a cough. He then became semi- unresponsive. The resuscitation team were called and his blood pressure and oxygen saturations were said to be normal. A CT scan was done at 13.29 hours and was said not to demonstrate any significant abnormality, especially no evidence of an air embolism in the chest. Regulation 28 – After Inquest Document Template Updated 30/07/2021 A CT head scan was also done which demonstrated some low-density areas in the brain and the possibility of a fat embolism was suggested, or an air embolism in the cerebro-vascular fluid. The CT scan was reported at 1606 hours with these possible diagnoses mentioned. This led to a discussion with the neurosurgical unit at Addenbrookes who advised that this was not a surgical issue, but that a Neuro-Radiologist should be consulted if local Radiologists needed further advice. Care was then handed over to the resusitation team. Mr Crocker’s family gave details of him being significantly unwell after he was taken to the Emergency Department. On the balance of probabilities this was due to a cerebral air embolism caused by the biopsy, a rare but recognised complication of any invasive procedure. At 2004 hours a CT chest scan was ordered due to haemoptysis. Mr Crocker collapsed in the CT department and had a brief seizure and then respiratory/cardiac arrest. After 2 cycles of CPR, return of spontaneous circulation was achieved and he was transferred to ICU. After his condition had been appropriately stablised, the Trust’s Lead Consultant in the Hyperbaric Unit was contacted to discuss the possible benefit of delayed hypobaric treatment for the cerebral air embolism (evidence was that treatment is most effective if it is commenced within 4-6 hours of the embolism occurring). It was agreed to commence such treatment and this took place on 3, 4 and 5 May 2023 but did not lead to an improvement in his condition. On 7 May 2023 a diagnosis of a vegetive state was made and he was provided comfort care and end of life support and died at James Paget University Hospital on 10 May 2023. 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: (brief summary of matters of concern) 1. 2. 3. 4. I heard evidence that there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure. I heard evidence that nationwide and across all levels of specialism and seniority, there was a lack of knowledge and that air embolism is not something that is routinely taught as part of the training of doctors. While it is accepted that this is rare, it is life threatening if not appropriately treated swiftly. I also heard evidence that in areas where enhanced training has been provided, due to adverse incidents such as Mr Crocker’s death, there appears to be increased numbers of cases. This leads to the question of whether the lack of knowledge means that such cases are missed and unreported and the rise is due to greater awareness. I heard that, in some cases, with timely treatment, outcome may be significantly improved, but that with delayed recognition and therefore delayed treatment, death is more likely. I heard evidence that there is ongoing work with the Royal College of Radiologists to provide them training on this issue, but that training was needed to ensure that all other specialties who may encounter this condition have raised awareness nationally. 6 ACTION SHOULD BE TAKEN Regulation 28 – After Inquest Document Template Updated 30/07/2021 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. YOUR RESPONSE 7 You are under a duty to respond to this report within 56 days of the date of this report, namely by September 24, 2024. 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: Mr Crocker’s Next of Kin James Paget University Hospitals NHS Foundation Trust For interest I am also sending a copy to the Royal College of Radiologists. I am aware that they are already undertaking work with REAL and working on a training module. A copy will also be sent to: Department of Health Healthcare Safety Investigation Branch Healthwatch Norfolk NHS England and NHS Improvement 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 release or the publication of your response by the Chief Coroner. 9 Dated: 01/08/2024 Samantha GOWARD Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH Regulation 28 – After Inquest Document Template Updated 30/07/2021 Regulation 28 – After Inquest Document Template Updated 30/07/2021
8 responses 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.
British Thoracic Society Ms Samantha Goward Area Coro ner fo r Norfo lk County Hall Martineau Lane Norwich NRl 2DH 22 August 2024 Dear Ms Goward, Regulation 28: Report to prevent futures deaths Mr Derryck Crocker We have been asked to respond to the Regulation 28 form which has been passed to us by the Royal College of Physicians, London. We are deeply sorry to hear of the sad death of Mr Crocker and we send our condolences to Mr Cracker's family. As the report notes, the occurrence of an air embolism is a rare but recognised complication that can occur following an invasive procedure. In the case of CT guided lung biopsy, radiology colleagues will be aware of the importance of timely and appropriate treatment, as will respiratory colleagues. We suggest that this would be suitable for a patient safety alert such as those issued by NHS England to ensure that there is a timely and appropriate response to such cases, with the intention of preventing future deaths. The British Thoracic Society will make a proposal to the NHSE Patient Safety Committee and will provide any advice and support requested of us. We have copied this letter to the Royal College of Physicians, London, the Royal College of Radiologists and the British Society of lnterventional Radiology. Yours sincerely, Chair of the Board of Trustees British Thoracic Society Copy Royal College of Physicians, London, Royal College of Radiologists British Society of lnterventional Radiology British Thoracic Society Registered Office: 17 Doughty Street/ London WClN 2PL bts@brit-thoracic.org.uk • www.brit-thoracic.org.uk England and Wales Charity No.285174 Scottish Charity No. SC041209 Company Registration No. 1645201
NHS}
James Paget
University Hospitals
NHS Foundation Trust
Our ref
28" November 2024
Lowesiofi Road
Gorleston
Ms Samantha Goward LLB (Hons). Great Yarmouth
Norfolk Coroner’s Service Norfolk
County Hail NR31 6LA
Martineau Lane
NORWICH
mre a
Dear Ms Goward
INQUEST — MR DERRYCK CROCKER — 22/06/1945
Further to your letter, dated 1% August 2024 in which you requested further
assurance and update against the actions identified in the Inquest for Mr Crocker and
you asked for the information to be returned ta you bv the end of September 2024. i
apologise for the delay in responding to your request.
Foliowing the sad passing of Mr Derryck Crocker on 10" May 2023, an inquest was
heard and closed by yourself on 30" July 2024.
During the inquest P| Consultant in Acute Medicine, gave oral evidence in
relation to the Root Cause Analysis Investigation Report and associated Action Plan.
As per your letier it was noted that further assurance was requested in relation to two
of the actions, as follows:
Action 2b — HM Coroner requested an update following the observational peer
review, being completed by an interventional radiologist from Papworth Hospital,
which is scheduled to take place on 7" August 2024.
Action 6a — HM Coroner requested a copy of the approved SOP in relation to
deterioration of patients following lung biopsy.
In addition during the inquest our team noted that further assurance was requested in
relation to one further action as follows:
Action 27 — HM Coroner requested an update in October 2024 in relation to the
training module on air embolism being produced by EMM for the Royal College
of Radiologists.
| am now in a position to be able to provide the requested updates as follows:
Action 2b — The observational peer review was completed in August 2024 by [jj
Consultant Cardiothoracic Radiologist at Cambridge University
Hospitals. The Trust received the written outcome report {as per attachment 1).
On receipt of the peer review report in September the Radiology leads have generated an action plan (as per attachment 2} for the department to address the areas of improvement highlighted in the report. They have been meeting regularly with the specialist Interventional Radiology leads to report and update progress on these aciions. Monitoring of the incident action plan and peer review action plan is through reporting to the Radiology Department Governance meetings and by exception to their Divisional Governance meetings. Escalation for actions not being met, as required, is to the executive Jed Hospital Management Group with assurance reporting to the Trust Patient Safety and Quality Committee. Action 6a — A standard operating procedure for the management of a deteriorating patient after image guided lung biopsy has now been implemented (as per attachment 3). Action 2f — QM Consultant Anaesthetist at the Trust, has received confirmation that the air embolism training module has now been made availabie to access by all Royal College of Radiologist members both in the UK and abroad and that a REAL (Radiology Education and Learning) talk has also been scheduled. | hope the attached provides the assurance requested, however, if you do need any further information please do not hesitate to contact me. Yours sincerely Chief Executive Enc.
20 September 2024 Dear Ms Goward, Re: Regulation 28: Report to Prevent Future Deaths in the matter of Derryck Lynn Crocker Thank you for sending us a copy of your report regarding the sad death of Mr Crocker. We have jointly reviewed the information available to us in the report via our Safe Anaesthesia Liaison Group (SALG). SALG is a collaborative project between the Association of Anaesthetists, NHS England’s Patient Safety team and the Royal College of Anaesthetists (RCoA). One of its core objectives is to analyse anaesthesia-related serious incidents and to share the learning with the specialty across the UK. In your report, you highlighted your concern that doctors across all specialties undertaking invasive procedures were not trained on the risk of air embolism following any invasive procedure. In further correspondence, you confirmed that you were sending this report to us as representatives of a specialty that undertakes invasive procedures, rather than due to any concerns about the care that Mr Crocker received from anaesthetists or intensivists. Anaesthetists directly undertake a range of invasive procedures that potentially could be complicated by air embolism, such as the insertion of central venous catheters. We can confirm that the risks of air embolism, and how to spot the signs and symptoms of an air embolism, are included in anaesthetists’ training to conduct these procedures1. Anaesthetists are often involved in the care of patients who are having invasive procedures delivered by other specialities. Air embolism, as a cause of a clinical emergency, is included in the Association of Anaesthetists’ Quick Reference Handbook (QRH)2. The QRH is a collection of guidelines on unexpected or uncommon anaesthesia-related emergencies. It aims to ensure the response to a crisis is as organised and all-encompassing as possible, at a time when the cognitive load can impair performance. The QRH helps clinicians focus on delivering care, using the skills and knowledge they already have. All anaesthetists are required to become familiar with guidelines for the management of anaesthetic emergencies, such as the QRH, so that they are automatically reached for in a crisis.3 Immediate access to emergency guidelines, such as the QRH, in all locations where anaesthesia is given is part of the standards for the RCoA’s Anaesthesia Clinical Services Accreditation (ACSA) scheme. We would be happy to respond to any questions that you might have. Yours Sincerely President Royal College of Anaesthetists President Association of Anaesthetists References 1. S Webber, J Andrzejowski, G Francis, Gas embolism in anaesthesia, BJA CEPD Reviews, Volume 2, Issue 2, April 2002, Pages 53–57, https://doi.org/10.1093/bjacepd/2.2.53 2. The Association of Anaesthetists, Quick Reference Handbook, June 2023 (https://anaesthetists.org/Home/Resources-publications/Safety-alerts/Anaesthesia- emergencies/Quick-Reference-Handbook) 3. Royal College of Anaesthetists, Guidelines for the Provision of Anaesthesia Services for the Perioperative Care of Elective and Urgent Care Patients 2024 (https://www.rcoa.ac.uk/gpas/chapter-2)
Ms Samatha Goward Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DS 13th September 2024 Dear Ms Goward, Further to your Prevention of Future Deaths Notice following the conclusion of your inquest (30th July 2024) into the death of Derryck Lynn Crocker who died on 10th May 2023, we like to extend our sympathy and condolences to the family and friends of Mr. Crocker. We note the known rare side-effect of an air embolism following lung biopsy occurred outside of the emergency department. Emergency physicians are aware of the possibility of air embolism following invasive procedures such as the insertion of central lines and therefore take precautions, such as ‘head down’ positioning, to prevent this. However, we are grateful to you for highlighting this tragic case and we intend to raise awareness of the condition of air embolism amongst RCEM members by re-issuing a previously published case report involving air embolism as well as considering providing specific guidance on the recognition and management of air embolism on our RCEM eLearning educational platform. Yours sincerely, Chair, Quality in Emergency Care Committee
Subject: Norfolk Coroner - Regulation 28 report Sent: From: Consult To: 27/08/2024, 11:53:43 Norfolk Coroner Categories: Blue Category WARNING: External email, think before you click! Dear Norfolk Coroner team, The Royal College of Physicians (RCP) notes the content of the Regulation 28 report for the prevention of future deaths related to the death of Derryck Lynn Crocker. We send our sincere condolences to the family. We recognise that air embolus is a serious but rare complication of invasive procedures. For trainees in respiratory medicine their curriculum states related to lung biopsy: “Trainees must be able to outline the indications for these procedures and recognise the importance of valid consent, aseptic technique, safe use of analgesia and local anaesthetics, minimisation of patient discomfort, and requesting help when appropriate. For all practical procedures, the trainee must be able to recognise complications and respond appropriately if they arise, including calling for help from colleagues in other specialties when necessary”. In addition, air embolus is a recognised complication of central line infection and all physician trainees at Internal Medicine Stage 1, with similar guidance in their curriculum. We would support the British Thoracic Society recommendation of an NHS Patient Safety Alert to raise wider awareness. Please confirm receipt of this email. Kind regards, | Consultation manager Membership Support and Global Engagement Department | Royal College of Physicians 11 St Andrews Place | Regent's Park | London | NW1 4LE Direct line +44 (0)20 3075 1459 www.rcp.ac.uk We value taking care We value learning We value being collaborative
$& Royal college }9, surgeons 3? of England e@ Samantha Goward Area Coroner for Norfolk County Hall Martineau Lane Norwich NR12DH 19 September 2024 Dear Mrs Goward Regulation 28 Report to Prevent Deaths: Mr Derryck Lynn Crocker Matter of Concern: That there is a lack of understanding of the signs and symptoms of an air embolism and the risk of this following any invasive procedure, and that air embolism is not something that is routinely taught as part of the training of doctors. Royal College of Surgeons of England response, on behalf of the Joint Committee on Surgical Training (JCST): Air embolism is something that is well recognised by those involved in Vascular lnterventional Radiology and lung biopsies i.e. those closely related to the procedures where it is likely to be complication of (e.g. those involved in obstetrics will be more aware and up to date with amniotic fluid embolism) but other specialties are likely to be much less familiar. In terms of specific surgical specialties, we would draw your attention to the following examples: Cardiothoracic surgery: There is a recognised association with air embolism during cardiothoracic surgery particularly involving cases where the cardiac chambers are opened and or cardiopulmonary bypass or mechanical circulatory support is used to support the patient's circulation. A knowledge of techniques to de-air the circulation, as well as the pathophysiology or complications of air embolism is covered in several areas within the curriculum. Neurosurgery: The risks of air embolism are regularly discussed with trainees whenever operating near the venous sinuses. The principal concern being large quantities of air entering the veins within the head and going to the heart causing haemodynamic instability In respect of the core surgical curriculum completed by all surgical trainees: irm@rcseng acuk We have reviewed the MRCS examination (2013 updated 2018) & Core Surgical Curriculum (CST) (2017 and 2021) syllabus, and discussed this issue with colleagues who are instructors of the Advanced Trauma Life Support (A TLS) and Care of the Critically Ill Surgical Patient (CCrlSP) courses. Assessment and management of thromboembolism is part of the scope of the MRCS/CST curriculum and the part of the syllabus which involves placement/management of central line will have in general included considerations for complications such as air embolism. An understanding of the risks of anaesthesia and medical gases is generic to surgical training. We believe it to be a commonly asked question in the examination. There is a brief mention of it within ATLS. However, delivery of courses can vary and such a specialised complication/subject will not have been covered consistently. There isn't a CCrlSP scenario related to air embolism for the same reason. We will flag this within our governance mechanisms for ATLS and CCrlSP (A TLS steering group and CCrlSP clinical lead and working party) and will draw attention to the risk of air embolism with our membership through our regular communications. Thank you for drawing this to our attention. Yours sincerely Chief Executive irm@rcseng acuk
18 September 2024 Dr Samantha Goward Area Coroner for Norfolk County Hall Martineau Lane Norwich NR1 2DH (Via email: ) Dear Dr Goward Regulation 28: Report to prevent future deaths Thank you for your letter of 1 August 2024 concerning the death of Derryck Crocker following an air embolism. The Royal Society of Medicine is a membership organisation, including 55 specialist sections that provide an extensive programme of educational events to ensure doctors keep up to date in their respective fields. This puts us in an excellent position to provide ongoing education about the risks of air embolism and its management. In response to Regulation 28, I can confirm the following actions: • The Presidents of all the relevant specialist Sections at the RSM have been asked to add in the risks of air embolism and its management to any appropriate educational events for the coming year. • The Patient Safety section, which is running its 14th annual event for those at medical school and junior doctors, will use its Patient Safety Summit on 14 November 2024 to elevate the profile of the risks of air embolism and the signs and symptoms that might be seen following any invasive procedure. This will be covered by a specialist in anaesthetics. Yours sincerely, PRESIDENT Patron: HM King Charles III Address: 1 Wimpole Street, London, W1G 0AE Website: www.rsm.ac.uk ▪ Telephone: Charity no: 206219 ▪ Vat reg no: 524413671
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