Desmond Statton

At approximately 12 noon blood gasses were taken from Mr Statton. It is likely that immediately prior to the blood being taken, Mr Statton’s skin was cleaned with a solution containing Chlorhexidine notwithstanding guidance issued three weeks previously.

At approximately 2.30 that afternoon Mr Statton had a cannula inserted in preparation for the administration of Contrast Medium. Again it is likely that immediately prior to this procedure his skin was cleaned with a solution containing Chlorhexidine.

Mr Statton was then taken by wheelchair to undergo his CT Scan. Prior to the scan being undertaken, the Radiographer took the deceased’s medical history and asked whether he suffered from any severe allergies. The form records that Mr Statton said that he did not.

The Radiographer checked on her computer system whether there were any alerts. She found none. In evidence, it was established that the Radiographer’s computer system did not contain information relating to alerts and allergies contained on other computer systems available elsewhere in the Hospital. It was further established that the Radiographer did not know of the conclusions of investigations .

Mr Statton was administered the Contrast Medium and almost immediately suffered a severe allergic reaction. Blood taken shortly after his collapse showed a mast cell tryptase level of 175 (normal 2 – 14). He was said to have developed a rash at the time of his collapse.

Mr Statton could not be resuscitated and died.

At Inquest, I found, as a matter of fact, that it was more likely than not that Mr Statton suffered an allergic reaction to the Contrast Medium rather than the Chlorhexidine used to clean his skin on the two occasions prior to the CT Scan.

Coroner’s concerns

1. 1. Radiographers are not able to access information concerning alerts or allergies contained on different computer programmes elsewhere in the Hospital.

1. 2. Derriford is a tertiary hospital and accepts admissions from other hospitals elsewhere in the South West. Clinicians in Derriford are not able to access information relating to alerts or allergies recorded on the computer programmes in other hospitals.

1. 3. Nursing staff are not sufficiently aware that Chlorhexidine is a growing cause of anaphylactic reactions and that it is contained within solutions used to sterilise the skin (and elsewhere.)

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.

Your response

You are under a duty to respond to this report within 56 days of the date of this report, namely by 29 January 2014. 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.

Copies and publication

I have sent a copy of my report to the Chief Coroner and to the following Interested Persons namely, ,

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.