University Hospitals Birmingham NHS Foundation Trust

3. Ms A complains about the treatment University Hospitals Birmingham NHS Foundation Trust provided to her partner, Mr P. She says on 29 June 2023, the Trust failed to manage his tracheostomy site appropriately, resulting in the tube becoming dislodged and causing a tracheal bleed. She also complains the Trust did not manage this bleeding properly, which subsequently led to a haemorrhage.

4. Ms A says the Trust’s failings led to Mr P suffering a brain injury and requiring 24hr nursing care.

5. Ms A would like an explanation of why this happened and financial remedy which would cover Mr P’s future care.

6. On 15 June 2023, the Trust admitted Mr P to its acute ward under the care of the Intensive Care Unit (ICU), with a diagnosis of possible delirium.

7. On 22 June, the Trust decided to carry out a tracheostomy on Mr P due to worsening symptoms. A tracheostomy is a surgical procedure that creates an opening in the neck to facilitate breathing when the usual airway is obstructed or compromised.

8. The same day, the Trust informed Ms A of their plan and explained the associated risks of the procedure.

9. On 29 June, Mr P experienced bleeding from the tracheostomy site, which resolved.

10. In the early hours of 30 June, Mr P suffered a significant bleeding episode, which the Trust’s ICU and ENT teams managed.

11. During this episode, Mr P had a cardiac arrest, resulting in a brain injury.

15. Mr P was admitted to the Trust's acute ward on 15 June 2023, under the care of the Intensive Care Unit (ICU), with a diagnosis of possible delirium.

16. Records show on 22 June 2023, due to Mr P’s rising blood pressure, increased heart rate, irregular breathing patterns, and him being unresponsive to voice or pain, and not following commands, the Trust decided to perform a tracheostomy.

17. Before the procedure, the Trust informed Mr P’s partner, Ms A, about the decision. It explained there was uncertainty about the permanence of the tracheostomy and outlined potential complications, including lung damage, bleeding, and infection.

18. Mr P’s records include a critical care form. The form documents the tracheostomy care the Trust performed daily on him. This includes checking his tracheostomy equipment, maintaining cuff pressure, ensuring emergency tracheostomy equipment was available, monitoring ventilator alarms (to address airway and respiratory needs), assessing the oxygen cylinder and inspecting the tracheostomy site daily.

19. Mr P’s nursing records shows the Trust observed and managed secretions in the tracheostomy site. On 23 June, moderate thick secretions were cleared using saline. On 26 June, the Trust removed smaller amounts of secretions. On 28 June, deep suctioning cleared a large amount of thick, pale green secretions, which stabilized his respiratory rate and oxygen levels.

20. On 29 June at 6:15am, while a nurse was changing Mr P’s tracheostomy dressing, they noted bright red bleeding from the site. The nurse informed a doctor of the bleeding who advised applying pressure. The doctor stated they would attend as soon as possible. Records indicate the doctor did not attend immediately, but the bleeding reduced on its own.

21. At 7:41am, the doctor reviewed the tracheostomy. The doctor noted that gauze was in place, the bleeding appeared to have settled, and they advised the nurses to monitoring the tracheostomy site.

22. At 8:10am, the Trust changed Mr P’s tracheostomy to a Passy Muir Valve (PMV), a one-way speaking valve that allows air to enter through the tracheostomy but directs exhaled air through the mouth and nose to enable speech. During this procedure, Mr P began coughing and the tracheostomy site started bleeding again. The Trust cleaned the area, applied medical skin glue (Surgi Seal), and replaced the dressing.

23. At 8:30am, assessment showed the tracheostomy was secure, and Mr P’s oxygen levels, breathing rate, and carbon dioxide levels were normal and stable. His lungs were receiving air without abnormal sounds, but the lower parts of the lungs were slightly quieter.

24. At 10:15am, records show Mr P was tolerating self-ventilation with the PMV well, and the Trust placed a plan to increase his time on the valve the following day. At this point the Trust transferred him to a recliner chair where he was able to reposition himself with some assistance. Records show he spent about 3 hours on the chair before he returned to the bed at 1.30pm.

25. At 8:10pm, Mr P’s tracheostomy site remained secure. Both lungs were receiving air, and suctioning removed thick mucus mixed with some blood.

26. At 8.56pm its noted Mr P was pulling at the nasogastric tube (NGT) and tracheostomy. To prevent this Mr P wore thin mittens. The records show his trach cuff was inflated, and his oxygen saturation was stable.

27. At 11:00pm, Mr P’s trachea site bled again; this was a minor bleed that spontaneously stopped bleeding. The Trust estimated he lost 50–100ml of blood. An ICU doctor reviewed him and noted his oxygen levels, blood pressure, and heart rate remained stable. The ICU doctor redressed the site and noted there was no further bleeding at that time.

28. At 12:40am on 30 June, Mr P began bleeding heavily from the tracheostomy site. The ICU team was informed and treated him to control the bleeding. It checked blood test results and arranged a blood transfusion. When Mr T began bleeding from his mouth as well as the tracheostomy site ENT was called.

29. Mr P’s oxygen levels dropped to 60%. The ITU team attended and used a bag-valve-mask (BVM) with a Mapleson C circuit, a manual breathing setup, to push oxygen into a his lungs. This temporarily improved his oxygen levels to 98%. His oxygen levels dropped again. The Trust could not ventilate him through his tracheostomy.

30. ENT arrived and tried without success to restore his ventilation by replacing the tracheostomy tube. Mr P went into peri-arrest (close to cardiac arrest) and attempts to ventilate him through the upper airway also failed because his mouth and throat were filled with blood and clots, preventing visibility and the passage of a breathing tube.

31. The Trust started its Major haemorrhage protocol. A haemorrhage is a severe or active bleeding. During this time the team treating Mr P included an ITU Specialty Registrar, an Advanced Critical Care Practitioner (ACCP), and a Core Trainee Year 2.

32. The records show Mr P went into a hypoxic cardiac arrest, caused by the lack of oxygen. This lasted approximately 10 minutes. During the arrest, Mr P’s airway remained full of blood and clots. The first attempt to place a breathing tube entered the oesophagus. The team removed and successfully reinserted the tube. His oxygen levels returned to normal.

33. Once stabilised, ENT performed a bronchoscopy and found no active bleeding within Mr P’s trachea. The Trust took an Xray which confirmed the team had correctly placed the tube. Mr P received two units of blood.

34. Records show an ENT reviewed Mr P’s tracheostomy site at 3am. It noted no fresh bleeding at the site. The ENT applied a surgical sheet over the site and applied further dressings over the top. A surgical is a sterile, plant-based fabric used during operations to stop bleeding.

35. Records show on 1 July the Trust explained Ms A that Mr P had experienced a cardiac arrest during which his heart had stopped for around 10 minutes, resulting in a brain injury. It said its management plan was focused on preventing any further brain injury.

Managing the tracheostomy site

36. Ms A says complains the Trust did not manage his tracheostomy site appropriately, which resulted in the tube becoming dislodged and causing a tracheal bleed.

37. The NTSP Trach guidance states complications related with tracheostomy care can be prevented by performing basic care effectively. It recommends considering the following when caring for a patient with a tracheostomy:

• Regular cleaning of the tracheostomy tube to prevent blockages caused by secretions or blood.

• Daily inspection and care of tracheostomy site, which is the surgically created opening in the neck leading to the windpipe (trachea). The tracheostomy site should be kept clean and dry using absorbent dressings.

• Maintenance and regular review of cuff pressures to ensure proper function.

• Frequent suctioning to keep the airway clear, addressing secretions to reduce the risk of aspiration and improve the patient’s comfort.

• Capnography monitoring is essential to assess the patient's breathing, blood circulation, and metabolism. Capnography continuously measures the concentration of carbon dioxide (CO₂) in exhaled breath, providing critical information about the patient's condition.

• Patients with tracheostomies should be supported within the Intensive Care Unit (ICU).

• Essential tracheostomy equipment, such as spare tubes and suction devices, should always be readily available to ensure prompt response to any emergencies

38. The records show the Trust checked Mr P’s tracheostomy site, equipment, and cuff pressures daily. It also cleared any secretions or blood in the tracheostomy site as needed. The Trust consistently monitored oxygen levels, respiratory rate, and ventilator alarms. Mr P was also under the care of the Trust ICU team.

39. We can see the Trust acted in line with guidance on the way it managed Mr P’s tracheostomy site. We hope this reassures Ms A the care Mr P received was appropriate.

Managing his bleeding

40. Ms A complains the Trust did not manage the bleeding from Mr P’s tracheostomy site appropriately which subsequently led to a haemorrhage (severe or active bleeding).

41. NTSP Trach guidance lists out the risks of tracheostomy one of which includes bleeding and airway loss.

42. NTSP Trach Bleeding 2018 outlines recommended actions to take in responding to tracheostomy-related bleeding, emphasising it is always potentially serious and should involve an experienced clinician early on. The recommended actions are:

• Sit the patient up • Administer supplemental oxygen • Measure vital signs • If actively bleeding or more than 10 millilitres of bright blood is evident (e.g. soaked stoma dressing and blood leaking beyond dressing), activate emergency response • If less than 10 millilitres of bright blood are contained within the dressing, the patient needs urgent clinical review • In cases of major bleeding or the patient has associated respiratory distress, activate emergency response • Inflating the tracheostomy cuff or applying direct pressure to the bleeding point can temporarily help in bleeding situations • Secure the airway with advanced airway assistance and transfer the patient to the operating theatre or interventional radiology for further intervention All cases require consultation with the treating surgeon (thoracic, ENT or maxillofacial) for planning investigations and interventions

43. Our clinical adviser explained these steps are recommendations and may not all always be done at once, rather it depends on the clinical need of each individual patient.

1st bleeding (6:15am, 29 June)

44. Following the doctor’s advice, the nurse applied pressure to the site, which helped to reduce the bleeding. According to the guidance, if less than 10 millilitres of bright blood is visible at the tracheostomy site, an urgent clinical review is required. The records show it took approximately an hour and 30 minutes for the doctor to review Mr P.

45. Our clinical adviser clarified the bleeding was self-limiting and the nurse followed the doctor's instructions, which assisted in controlling the bleeding. Our adviser told us an urgent review was not clinically required as the bleeding was self-limiting. They also explained the nurse could have contacted the doctor again if the bleeding had continued.

46. We have seen the nurse acted in accordance with the doctor’s guidance, which indicates the Trust reviewed the tracheostomy site, and the bleeding subsided as a result. We have also seen a doctor conducted a review of the site and noted the bleeding had resolved. We can see the Trust acted in line with the guidance in managing this bleeding.

2nd bleeding (8:10am, 29 June)

47. The next bleeding occurred when the Trust passed an airway device through the tracheostomy site. The Trust cleaned the site, applied medical skin glue and replaced the dressing. After this incident the Trust reviewed his tracheostomy site and respiratory system and found it to be secure and stable. Our adviser told us this was clinically appropriate for Mr P.

48. We can see the Trust acted in line with NTSP Trach guidance by ensuring it kept the site clean and dry with absorbent dressings, and in line with NTSP Trach Bleeding 2018 by measuring his vital signs after it secured the site.

3rd bleeding (11pm, 29 June)

49. This bleeding was self-limiting, and the Trust estimated Mr P lost approximately 50–100ml of blood. As this volume exceeds 10ml, it can be classified as active bleeding under the NTSP trach bleeding guidance. This ordinarily calls for an emergency response. We have seen evidence an ICU doctor reviewed Mr P and found his vital signs were stable.

50. Our clinical adviser explained, though the bleeding was significant, it settled without causing harm to the patient. As such, it was reasonable the Trust did not activate an emergency response in this instance.

51. The guidance indicates active bleeding exceeding 10ml generally requires an emergency response. However, we note the emphasis is on continuous bleeding. In Mr P’s case, the bleeding ceased and did not persist, meaning an emergency response was not warranted. The Trust acted in accordance with the guidance by redressing the site, confirming Mr P's vitals were stable and there was no further bleeding.

Major bleeding (12.40am, 30 June)

52. Mr P’s tracheostomy site began bleeding heavily. The ICU team was promptly called to help manage the bleeding. Despite their efforts, they could not control the bleeding. Mr P began to bleed from his mouth. As a result, the ICU sought the intervention of the ENT team to stop the bleeding.

53. When the ENT team arrived, they attempted to replace the tracheostomy tube; however, these efforts were unsuccessful, and during the process, Mr P suffered a cardiac arrest. At that point, the Trust activated its major haemorrhage protocol.

54. Our clinical adviser explained the team attending to Mr P was an appropriate emergency response team. Furthermore, when the team recognised the situation was beyond their capacity to manage, they promptly sought additional support.

55. We can see that the Trust acted in line with guidance by initiating an emergency response when Mr P experienced respiratory distress. Relevant departments collaborated to seek intervention and investigate the situation further. Following the episode, both the ICU and ENT teams continued to review Mr P to support his recovery.

56. Reviewing each instance of bleeding, we can see Trust acted in line with NTSP guidance and NTSP Trach Bleeding 2018 to provide appropriate care in response to Mr P’s bleeding events. The level of intervention matched the severity of the situation at each stage.

57. We appreciate how distressing Mr P’s tracheostomy, subsequent bleeding and cardiac arrest were for both Mr P and Miss A. We hope our findings reassure Ms A that the Trust took appropriate and timely action to manage Mr P’s bleeding.

1. We have carefully considered Ms A’s complaint about University Hospitals Birmingham NHS Foundation Trust (the Trust). We are sorry to hear how Mr P has been affected. It is clear Mr P went through a challenging experience, and it has clearly been distressing for Ms A to witness this.

2. We have decided not to consider Ms A’s complaint any further as we have seen the Trust acted in line with guidance in the care it provided Mr P.