Ian Jacka
7 Dec 2023 · Coroner Guy Davies · Cornwall and the Isles of Scilly
The coroner's concerns
1. incomplete handover of critical care information
“There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to [the deceased]'s death.”
2. missing documentation of critical incident
“There was no entry in [the deceased]'s hospital notes to indicate the full extent of the critical incident of 5 June 2022.”
3. uninvestigated omission
“The error of omission was unexplained and has not been investigated by the NHS.”
4. lack of neurological status information
“The surgical and anaesthetic team had no reason to suspect a secondary brain injury. The team had no information on [the deceased]'s neurological status.”
5. delayed surgery due to missing information
“Had the surgical and anaesthetic team known of the extent of the critical incident of 5 June, the operation would have been delayed and further tests and assessments undertaken.”
6. failure to implement handover recommendations
“The Trust had chosen not to accept this recommendation but at the time the Trust made that decision it was not aware of the extent and significance of the error of omission.”
Responses
2023-0519-Response-from-Medicines-and-Healthcare-Products-Regulatory-Agency.pdf ↗· University Hospitals Plymouth NHS Trust
Stated action
“We have received no other incident reports within the last 10 years where an issue occurred with AEC and jet ventilation being used together during endotracheal intubation.”
2023-0519-Response-from-National-Trust.pdf ↗· University Hospitals Plymouth NHS Trust
2023-0519-Response-from-University-Hospitals-Plymouth-NHS-Trust.pdf ↗· University Hospitals Plymouth NHS Trust
Stated action
“There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to [the deceased]'s death.”