Source · Prevention of Future Deaths

Boycie Chatterton

Ref: 2023-0483 Date: 27 Nov 2023 Coroner: Bernard Richmond Area: Inner West London Responses identified: 0 / 2 View PDF

The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.

Date 27 Nov 2023
56-day deadline 22 Jan 2024 est.
Responses identified 0 of 2
Child Death (from 2015)

Coroner's concerns

AI summary
The absence of a properly managed and funded national register for Tracheo-Oesophageal Fistula (TOF) cases likely hinders improved outcomes and survival rates.
View full coroner's concerns
During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. 1. I heard from experts giving evidence that the treatment of conditions such as OA with or without TOF would be better served by a properly managed and funded national register for TOF cases, which would in their view likely serve to improve outcomes and survival rates going forward.

Report sections

Investigation and inquest
An investigation was commenced into the death of Boycie [Alexander/Chatterton], aged 6 weeks. The investigation concluded on 1 September 2023. The conclusion in the inquest was:

Complication following surgical procedure

The medical cause of death was 1a Hypoxic-ischaemic brain injury 1b. Multiple respiratory arrests 1c. Complications following oesophageal atresia and tracheo-oesophageal fistula repair procedures.
2. VATER association.
Circumstances of the death
B was born at 36 weeks and 6 days gestation. At birth B was was diagnosed with congenital abnormalities including Oesophageal Atresia (OA) and Tracheo-Oesophageal Fistula (TOF), a condition denoted by a blind-ending upper oesophagus with the lower oesophagus connected to the trachea, which affects about 200 babies a year in England. B had an initial surgical procedure to disconnect the TOF and join the oesophagus, but the gap between the two parts of the oesophagus was too great at that time to join. This is known as long gap Oesophageal Atresia (OA), a condition which affects about 20 babies a year in England. Management of long gap OA is very significantly more challenging than non-long gap OA. There are different options for treatment of long gap OA. In this case the surgical team applied tension sutures to draw the oesophageal ends closer for later joining. B had a second planned surgical procedure to check whether the oesophagus was capable of being joined and it was not. At the third planned surgical procedure, an oesophageal anastomosis was performed. Following the third surgical procedure, B developed respiratory complications as a result of which he died.
Copies sent to
3. Chelsea and Westminster Hospital NHS Foundation Trust4. TOFS5. , Birmingham Children’s Hospital6. , Great Ormond Street Hospital

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Report details

Reference
2023-0483
Date of report
27 November 2023
Coroner
Bernard Richmond
Coroner area
Inner West London

Responses identified

Responses identified 0 of 2
2 responses not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 22 Jan 2024 (estimated).

Sent to

Department of Health and Social Care
NHS England

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