Source · Prevention of Future Deaths

Mark Hudson

Ref: 2014-0478 Date: 4 Nov 2014 Coroner: Alan Wilson Area: Blackpool & Fylde Responses identified: 1 / 1 View PDF

Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.

Date 4 Nov 2014

56-day deadline 30 Dec 2014 est.

Responses identified 1 of 1

Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary

Hospital procedures for urgent specialist care requests through the switchboard are insufficiently robust, risking unanswered or delayed responses that could harm patients.

View full coroner's concerns

At the conclusion of the inquest, I indicated to the Interested Persons that I proposed to write to the Trust by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009.

Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because:

Although encouraged by the steps that have been / are being taken internally at the Hospital further to this death, I remain concerned that there is a real risk that when the need arises for urgent provision of specialist care within the CICU department, such requests may go unanswered or be delayed. If CICU staff request such assistance via the Hospital Switchboard personnel at the hospital, I am concerned that the procedures in place are insufficiently robust to the extent that requests may not be followed up appropriately and to the potential detriment of the Patient requiring that urgent help.

I would therefore be obliged if the Trust would write to me in due course to confirm what steps if any the Trust proposes to take to address these areas of concern.

Responses

1 respondent

Blackpool Teaching Hospitals NHS Foundation Trust NHS / Health Body

22 Dec 2014 PDF

Action Taken

The Trust has undertaken training with senior members of the CICU Team, who are now competent in the placement of iGel tubes. A policy of using end tidal carbon monoxide monitoring for all intubated patients has been adopted. A review of the Out of Hours Anaesthetic Service was commissioned from the Royal College of Anaesthetists. (AI summary)

View full response

Dear Mr Wilson Re: Mark Bentley Hudson (Deceased) Thank you for your Regulation 28 Report to Prevent Future Deaths dated 4 November 2014 arising from the Inquest touching upon the death of Mark Bentley Hudson: The Trust has a strict procedure in place which has been drafted in line with the Resuscitation Council (2010) Resuscitation Guidelines_ In July 2012 the process used by the Resuscitation Council (UK) to produce the 2010 Resuscitation Guidelines was accredited by the National Institute for Health and Clinical Excellence (NICE): The NICE Accreditation Scheme recognises organisations that demonstrate high standards producing health or social care guidance. Users of NICE accredited guidance can therefore have high confidence in the quality of the information provided. The Trust's procedure is aimed primarily at healthcare professionals who are first to respond to an in-hospital cardiac arrest and is enclosed for your attention: For all in-hospital cardiac arrests help is summoned using a standard telephone number (2222) and cardiopulmonary resuscitation (CPR) is started immediately. All new staff members within the Cardiac Division are made aware of the 2222 procedure during their induction training: The cardiac arrest bleeps are tested at the commencement of each shift and if there is a failure of response the switchboard operators follow this up. The 2222 number alerts the switchboard to any medical emergency within the Trust and for this very reason all the 2222 calls are recorded for training and development purposes_ The switchboard staff , prior to lone working, follow a strict training programmes and have to satisfy a stringent list of competencies before they are allowed to answer the 2222 calls. must also feel confident that they are ready to receive and deal with the call: The switchboard department has advanced software technology which will enable the supervisor to field medical emergency calls to certain, more experienced members of the switchboard team. As you are aware the Trust has implemented the recommendations made following the serious untoward investigation into the circumstances surrounding Mr Hudson's death: It is clear that the Trust has learnt from this incident and as Matron ladvised at the hearing; to her knowledge within the Cardiac unit there has not been any other similar incident: RESEARCH MATTERS ANDSAVES LIVES IQDAY'S RESEARCH IS IQMORROWS CARE Blackpool Teaching Hospitals is a Centre of Clinical and Research Excellence providing quality up to date care: We are actively involved in undertaking research to improve treatment of our patients: A member of the healthcare team may discuss current clinical trials with you: Patient Safety Inormation CARE INVESTORS Gold 3 Standard integration IN PEOPLE AWARDS 2012 Disa Certitled membor (bzou Chairman: Mr Ian Johnson MA, LLM Chief Fxecuitive: Mr Garv Dnhertv They About Ative _ 1 'Bled

Blackpool Teaching Hospitals NHS] NHS Foundation Trust That said, as the Trust continually moves forward to improve its service, in addition the Resuscitation Team have undertaken training with senior members of Ihe CICU Team: Those senior members of the team are now competent in the placement of iGel tubes, which are easier to place than a formal tracheal tube and will allow satisfactory ventilation of patient until expert help arrives. We have adopted policy of using end tidal carbon monoxide monitoring for all intubated patients_ This technology allows rapid identification of inappropriate tube placements The Trust also commissioned a review of our Out of Hours Anaesthetic Service from the Royal College of Anaesthetists_ That report was received on 13 November 2014 and we are currently working our way through its recommendations in a further effort to improve our service_ The final action which has been taken is to convene meeting of myself with the Head of Resuscitation, the Head of Department for Cardiac Anaesthesia and the Matron for the CICU to discuss whether we need to make any further modification to our process_ hope the above satisfies your concern:

Report sections

Investigation and inquest

On 3rd September 2013 an investigation commenced into the death of Mark Bentley Hudson aged 50 years. The investigation concluded at the end of the inquest heard on 8th October 2014.

The record of the inquest confirmed as follows:

The Medical cause of death was Ia Myocardial Infarction 1b Severe Coronary Artery Disease and Thrombosis of the Right Coronary Artery Bypass Graft

11 Left Pulmonary Embolus and Diffuse Alveolar Damage

The conclusion of the Coroner as to the death was a Narrative conclusion as follows:

Mark Bentley Hudson was admitted to hospital on 20th August 2013 following three days of intermittent chest pain. After assessment he underwent urgent coronary artery bypass graft surgery. Although he initially appeared stable he went into cardiac arrest at approximately 22.45 hours on 25th August 2014 necessitating cardiopulmonary resuscitation. At approximately 00.10 hours on 27th August 2014 he again suffered a cardiac arrest. Efforts were made to ventilate him. Oesophageal intubation went unrecognised until the arrival of an anaesthetist. Despite efforts to revive him, death was pronounced at 01.15 hours later that morning.

Circumstances of the death

See the contents of section 3 above. The inquest was informed that further to admission to hospital on 20th August 2013 and having undergone urgent and necessary cardiac surgery, the Deceased had suffered a cardiac arrest on 25th August 2013 but had been resuscitated and stabilised.

However just after midnight on 27th August 2014 he went into ventricular fibrillation. Evidence was heard that a telephone call was made by staff on the Cardiac Intensive Care Unit [CICU] that the on - call Anaesthetist be bleeped with a view to her attending to provide assistance for Mr. Hudson. Shortly afterwards, the Anaesthetist having failed to appear at the CICU, two further requests were made by CICU staff for the Anaesthetist to be contacted.

An Anaesthetist gave evidence to the effect that she does not recall receiving the first two of those requests to attend CICU.

When the Hospital Trust undertook a Sudden Untoward Incident Review, it could not be established that the requests made by CICU staff had been received and acted upon. Switchboard staff are not expected to maintain a contemporaneous record of the calls they receive which require switchboard staff to then contact the Anaesthetist. The author of the internal review did accept that she could not rule out the possibility that the Anaesthetist had not been contacted in response to the first two requests and that the CICU staff had effectively been trying to maintain the Deceased’s airway whilst expecting the Anaesthetist to arrive imminently when she had not actually been notified.

At the inquest this appeared to be an issue that had not been fully appreciated during the Hospital Trust’s internal review.

Ultimately, the Anaesthetist did attend CICU to learn that a Surgical Registrar had - given the non appearance of an Anaesthetist - decided to take over airway management and attempted to intubate the Patient but that his airway had been compromised given that intubation had been carried out incorrectly.

Inquest conclusion

Mark Bentley Hudson was admitted to hospital on 20th August 2013 following three days of intermittent chest pain. After assessment he underwent urgent coronary artery bypass graft surgery. Although he initially appeared stable he went into cardiac arrest at approximately 22.45 hours on 25th August 2014 necessitating cardiopulmonary resuscitation. At approximately 00.10 hours on 27th August 2014 he again suffered a cardiac arrest. Efforts were made to ventilate him. Oesophageal intubation went unrecognised until the arrival of an anaesthetist. Despite efforts to revive him, death was pronounced at 01.15 hours later that morning.

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Report details

Reference: 2014-0478
Date of report: 4 November 2014
Coroner: Alan Wilson
Coroner area: Blackpool & Fylde

Responses identified

Responses identified 1 of 1

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 30 Dec 2014 (estimated).

Sent to

Blackpool Teaching Hospitals NHS Trust

Source links

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Data: judiciary.uk under OGL.