Source · Prevention of Future Deaths

Mike Fell

Ref: 2018-0100 Date: 5 Mar 2018 Coroner: Sarah Bourke Area: London Inner (North) Responses identified: 2 / 2 View PDF

Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.

Date 5 Mar 2018

56-day deadline 12 Aug 2018 est.

Responses identified 2 of 2

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Unused trauma lines lack a clear mechanism and documentation for ensuring they are "closed to air," with some lines lacking essential clamps, creating a risk of accidental opening.

View full coroner's concerns

(1) Whilst it is a matter of routine care to check that unused taps are "closed to air" , it is not recorded in Mr Fell's notes that the taps had been checked and were closed: It is unclear how or when the 3-way tap on the trauma line became "open to air" (2) The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed

Responses

2 respondents

Royal College of Anaesthetists Education

22 May 2018 PDF

Action Planned

The RCoA will publish information on central venous access line safety in the Patient Safety Update and include these issues in the updated AAGBI guideline Safe Vascular Access. The FICM and ICS are developing national guidelines on the prevention, detection, referral and treatment of air embolism associated with central venous access. (AI summary)

View full response

Dear Ms. Bourke,

Thank you for giving the Royal College of Anaesthetists (RCoA) the opportunity to respond to your Regulation 28 Report highlighting matters of concern regarding types of and practical use of central venous catheters and the risk of air embolism. In order to prevent future deaths, the RCoA has collaborated with the Association of Anaesthetists of Great Britain and Ireland (AAGBI), the Faculty of Intensive Care Medicine (FICM) and the Intensive Care Society (ICS) in preparing this response.

We note the Coroner’s concerns are: 1 Though it is a matter of routine care to check that unused taps are “closed to air”, it was not recorded in the notes that the taps were checked and were closed. 2 The particular central venous line used in this case did not come with a clamp that would have enabled the line to be clamped when not in use, so providing a second barrier, to air entrainment.

We are concerned that in practice there are many different types of central venous access line in use and that these devices, even if they have a clamp, can be used with different caps, that may or may not allow injection through them, including with three-way taps.

In addition, though there is national guidance on vascular access (Safe Vascular Access 2016, AAGBI) there is currently no national guidance on best practice with central venous access covering the use of clamps, caps and three-way taps with these catheters in an attempt to minimise the risks of air embolism.

Actions to be taken in response to these concerns:

• We will ensure these issues are brought to the attention of all trainees in anaesthesia and all Fellows and Members of the RCoA and AAGBI by publishing information in the Patient Safety Update, which is published quarterly by the RCoA on behalf of the Safe Anaesthesia Liaison Group (SALG - https://www.rcoa.ac.uk/salg), and is distributed to practising anaesthetists throughout the UK.
• When the AAGBI guideline Safe Vascular Access is updated these issues will be included.
• The Joint Standards Committee of the FICM and ICS is currently developing national guidelines on the prevention, detection, referral and treatment of air embolism associated with central venous access.
• In the meantime, we will inform individual trusts and health boards that they should ensure they have appropriate systems in place to prevent harm from air entrainment through such devices. We recommend that theatre departments, ICUs, HDUs and other clinical areas caring for patients with central venous catheters ensure that they examine local practice in terms of using only

catheters with clamps associated with each lumen, what is used to cap each lumen and how these catheters are checked and this is recorded.

I hope that these actions will satisfy you that the named organisations are taking appropriate steps to ensure that anaesthetists are aware of these issues and that the circumstances that led to the death of this patient are therefore less likely to occur again.

I would be happy to respond to any questions that you might have.

Barts NHS Trust NHS / Health Body

22 May 2018 PDF

Action Taken

Barts NHS Trust has rewritten its policy on the use of central lines and three-way taps, stating that three-way taps should not be used on central lines but self-sealing injection ports should be used. They are also discussing with their current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. (AI summary)

View full response

Dear Madam Coroner

Re: Regulation 28: Report to Prevent Future Deaths – Mike Fell

I write further to your prevention of future deaths notice arising from the inquest into the death of Mr Mike Fell at the Royal London Hospital. I am grateful to you for bringing the points you raise to my attention.

You raised two concerns about the use of three way taps on intravenous lines placed in central veins:

1 Whilst it is a matter of routine care to check that unused taps are closed to air, it is not recorded in Mr Fells notes that the taps had been checked and were closed. It’s unclear how or when the 3-way tap on the trauma line became open to air.

Although we regard this as routine care we have never recorded this in the notes. It is impossible to find out why this particular three way tap was left open; commonly the tap would be open to this port during injection of a drug or connection to an infusion. The tap should be closed before either the syringe is removed from the port or the infusion is removed. Less commonly the three way tap could be ‘opened’ to air by accident during movement of the patient. As a result of this incident we have re- written our policy on the use of central lines and three way taps which states that three way taps should not be used on central lines but self-sealing injection ports should be used. These are available and are in use across the trust. I enclose our up-to-date policy and a Trust wide safety notice to raise awareness of this complication and the new policy.

2 The Trauma lines used at the Royal London hospital did not come with a clamp which enabled a line not in use to be closed

These lines have been in use in the Trust for many years and the manufacturer of the line do not supply them with clamps. Currently the anaesthetic department are looking at other companies but it would appear none are made with clamps. We are discussing with our current supplier a change in design to allow a clamp to be fitted; they are interested in working with us as they see this as a problem nationally which has not been raised before in relation to this complication. Trust Executive Offices Pathology and Pharmacy 80 Newark Street Royal London Hospital London E1 2DR

Contact Telephone: 020 3246 0641

I am once again grateful to you for raising these important concerns relating to patient safety and I hope this response provides reassurance.

Kind regards

Chief Medical Officer Barts Health NHS Trust

Report sections

Investigation and inquest

On 6 November 2017, Coroner Hassell commenced an investigation into the death of Mike Fell who was born on 24 July 1952. The Investigation concluded at the end of the inquest; which was conducted by me on 5 March 2018. The conclusion of the inquest was a narrative conclusion: recorded a medical cause of death of: 1a Intracerebral haemorrhage 1b Cerebral air embolism 1c Elective abdominal aortic aneurysm repair performed on 26 October 2017

Circumstances of the death

Mr Fell had an elective abdominal aortic aneurysm repair by way of an open surgical procedure at the Royal London Hospital on 26 October 2017. He was slightly acidotic following surgery: He was transferred to the Adult Critical Care Unit whilst sedated and ventilated with a trauma line in place: The trauma line had a 3-way tap connected: Within an hour of arriving in the ACCU, the IV fluid line was removed from the trauma line and the connector was capped with a white bung: It was noted that there was no clamp on the trauma line. Mr Fell went into cardiac arrest about 3 hours after surgery: Immediately prior to cardiac arrest, there was a rapid fall in his end-tidal carbon dioxide levels_ During CPR, it was noted that the 3-way tap on the trauma line was "open to air" and it was sealed: It is unclear how or when the tap became "open to air"_ Mr Fell's heart started beating after 20 minutes of resuscitation but he remained very unstable: It was noted that he had a fixed, dilated right pupil. An emergency CT scan showed a large intracerebral bleed and air in his brain, liver and kidneys. Neurosurgeons advised that Mr Fell' s brain injury was unsurvivable: Mr Fell died at the hospital in the early hours of 27 October 2017. The evidence before me was that the air embolism was most likely to be the result ofthe 3-way tap on the trauma line being "open to air". The Roval London Hospital is in the process of revising its procedures regarding the use of trauma lines outside of operating theatres in light of the Issues raised by Mr Fell's death:

Action should be taken

In my opinion, action should be taken to prevent future deaths and | believe you have the power to take such action:

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Shared signals

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Report details

Reference: 2018-0100
Date of report: 5 March 2018
Coroner: Sarah Bourke
Coroner area: London Inner (North)

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 12 Aug 2018 (estimated).

Sent to

Barts Health NHS Trust

Royal College of Anaesthetists

Source links

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Data: judiciary.uk under OGL.