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Archie Hames

5 Jun 2014 · Coroner Martin Fleming · Surrey
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The coroner's concerns

  1. 1. detached tracheostomy tube causing airway obstruction

    “Independent expert testing of the tracheostomy tube (model AMFNF‐49) manufactured by Arcadia Medical and its attaching Velcro strap (model Trachi‐Hold mini, TR ACC) manufactured by Kapitex Healthcare, confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of [the deceased]'s tube”

Responses

2014-0259-Response-by-Department-of-Health.pdf ↗

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error