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recurance

Donald Till

11 Jan 2018 · Coroner Margaret Jones · Stoke-on-Trent & North Staffordshire

The coroner's concerns

  1. 1. lack of previous medical records

    “The deceased's previous medical records were not available. Different clinical decisions might have been made had they been available.”
  2. 2. anaesthetised on ward bed

    “The deceased was anaesthetised on a ward bed and it would have helped if he had been on a trolley with rapid tilt.”
  3. 3. missing suction button on sourced abronchoscope

    “Abronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing.”
  4. 4. absence of cricoid pressure and NG tubes

    “_Cricoid pressure and NG tubes were not used in this case.”

Responses

2018-0013-Response-by-University-Hospitals-of-North-Midlands.pdf ↗· University Hospital of North Midlands

Stated action

“The Trust is in the process of establishing a fully electronic case notes system, however, this is a planned programme over a number of years due to the scale and complexity of the requirements which also requires funding. Nevertheless, there are currently well established processes in place to access medical records for urgent admissions. All staff have access to the Trust 'file-fast case- note tracking system' to identify the location of the medical records and are able to request retrieval of”

Stated action

“Following the investigation into the care provided to Mr [name redacted] (Root Cause Analysis), it was identified that a rapid tilting trolley may have assisted in treating Mr [name redacted]. Measures were taken at the time to ensure that rapid tilt trolley was on standby for those high risk patients. It is my understanding that all beds and trolleys have a rapid tilt facility for emergency situations.”

Stated action

“In the initial stages of aspiration, 'blind' endotracheal suction can often suffice to treat the presenting problem. It is only once the majority of the aspirate has been removed by this technique, that it is possible to perform bronchoscopy to attempt to remove further debris and wash out the lungs. Throughout the UK, bronchoscopes are not a standard piece of equipment on the 'difficult airways trolley'. However, currently, our Critical Care areas are reviewing the use of disposable bronchosc”

Stated action

“The joint RCS/ASGBI emergency general surgery commissioning guidelines recommend placement and regular aspiration of nasogastric tubes in all patients with either large bowel or small bowel obstruction. However, this is a guideline only and a decision not to place a nasogastric tube can be taken by the treating surgeon”
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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.

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