Jackson Mitchell

27 Oct 2014 · Coroner Jacqueline Lake · Norfolk

The coroner's concerns

1. risk of future deaths
“In my opinion there is a risk that future deaths will occur untess action is taken”
2. liver damage from feeding fluid
“The damage found to [the deceased]'s liver at post mortem does not appear to be from the tip of the catheter but from the concentrated feeding fluid that was passing through it”
3. misplaced UVC tip
“Evidence was given that the ideal placement for a UVC tip is at the level of the diaphragm at approximately T9-T10 vertebral level. The UVC in this case was found to be in a lower lying position”
4. extravasation of fluid
“There is a presently unpublished study from Southampton which found 16 cases of extravasation of fluid from UVC over a 2 year period”