Kevin Mann
15 Jun 2017 · Coroner Nadia Persaud · London(East)
The coroner's concerns
1. proceeding with procedure despite visible left pneumothorax
“An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax.”
2. failure to review recent radiology before procedure
“The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure. Had she checked the system she would have seen the x-ray taken at 12:37 showing the large left pneumothorax. She would also have seen the outstanding request for a chest xray.”
3. continuing procedure after contrast entered left main bronchus
“The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus. The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage.”
4. lack of documentation of contrast amount
“There was no documentation available within the records of the amount of contrast handed to Mr [name redacted] or the amount of contrast ingested by him.”
5. policy lacks requirements for contrast documentation and preliminary checks
“The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing.”
Responses
2017-0190-Response-by-Barking-Havering-and-Redbridge-NHS-Trust.pdf ↗· Barking
Stated action · three months after the revised Protocol has come into use
“The Trust's Radiology Department has carried out an audit of Visipaque Swallows from May 2016 - June 2017 and will conduct a further audit three months after the revised Protocol (attached) has come into use to ensure understanding and compliance. If any issues are identified by the audit, the staff concerned will have 1:1 conversations with one of the Clinical Leads for Radiology and be required to undergo an observed procedure for assurance of skill.”