Inquest finds deficiencies in resuscitation led to death

Geldards’ Medical Negligence team recently concluded an Inquest on behalf of the family of SB, Deceased in the South Wales Central Coroner’s Court. The Inquest touched upon the care that he had received at the University Hospital of Wales, Cardiff leading up to his death on the 4th July 2019. The Inquest had been delayed for a number of months due to the impact of the Coronavirus pandemic.

SB had been admitted in late June 2019 under the Maxillo-Facial surgeons for surgery to remove a mouth and neck tumour and reconstruction. He underwent a lengthy operation on 27th June 2019 and as a result of the surgical onslaught a tracheostomy was fitted in his neck for breathing and ventilation. The surgery was extremely successful and was designed to be curative. He was admitted to intensive care following and by 28th June 2019 he was doing very well. The surgeons were so pleased with his progress that he was able to be discharged from the unit to the surgical ward A5 north. His family also noticed the improvements in him. Such was the speed of his postoperative recovery that the consultants were beginning to plan for his discharge home. Pathology of the removed specimens indicated that there was no metastatic disease which suggested that complete excision/removal of the tumour had been achieved by the surgery.

By 29th June, the tracheostomy site had started to ooze and concern was expressed by a nurse that it may have deviated. This was examined by one of the ward doctors, and it was confirmed to be in an acceptable position.

On the evening of Saturday 29th June 2019, the family had visited SB and all was well. They left the ward at 8pm following the end of visiting hours in a satisfied mood as SB was continuing his improvement post-surgery and plans for discharge home were now being considered properly.  However, from then on matters deteriorated.

At around 1.50am on the 30th June 2019, a nurse assisted SB with passing urine. Suddenly, he lost consciousness and suffered a cardiac arrest.  He was returned to his bed and CPR was commenced. Unfortunately, an important piece of tracheostomy kit known as an inner tube was missing from the tracheostomy and a spare, which should have been by his bedside was also absent.  This vital piece of kit was unique to the “Tracheo Twist” tracheostomy which SB had been fitted with. It was a tool/mechanism to connect to an external source of ventilation to restore the airway and thereafter return circulation. The anaesthetist who attended the arrest was unable to ventilate via the tracheostomy because of the absent inner tube and its spare. Unfortunately, as a result of delays in locating a spare inner tube, the resuscitation was significantly delayed. Return of spontaneous circulation was achieved after about 12 minutes of cardiac downtime. Unfortunately, this was too long to avoid a hypoxic brain injury and SB died on the 4th July 2019.

The Inquest heard evidence from 28 witnesses over a period of 3 days. Crucially, evidence from the Health Board’s own consultants confirmed that the absence of the critical inner tube resulted in a delay in replacing a respiratory circuit which more than minimally contributed to the period of hypoxia and subsequent death. The Court was advised that Neuron death starts to occur at 4 – 5 minutes post-arrest.

HM Coroner, David Regan, found that the absence of the inner tube was crucial as this prevented the doctors from connecting SB to an external oxygen circuit which would have ventilated him quicker. Had this been done, then the external oxygenation would have been connected earlier than was the case. Recording a Narrative verdict, he found that deficiencies in resuscitation were causative of the death and SB had died as a result of cardiac arrest when resuscitation efforts were compromised by the absence of an inner tube.

HM Coroner rejected the submission that Article 2 of the European Convention on Human Rights (incorporated into the Human Rights Act 1988) had been breached to the extent that the State through its agents had failed to meet its right to life obligations in respect of its citizens in particular SB. Nevertheless, he did find deficiencies in treatment. He also did not make a Regulation 28 Prevention of Future Deaths Report as the Health Board had submitted a detailed Improvement Plan, which amongst other things, confirmed that additional tracheostomy tubes were to be available on wards and the all important “requirement for an Inner Tube to be in situ at all times” (our emphasis).

The family remained dignified throughout a difficult time, having to listen to evidence about what happened and that, in particular, the absence of a small piece of plastic was responsible for SB’s death. Given the findings, substantial damages will now be claimed in a civil action for negligence.