Michael Walton
4 Jul 2024 · Coroner Georgina Nolan · Newcastle and North Tyneside
The coroner's concerns
1. unavailable preferred cannula
“The surgeon's preferred choice of cannula was not available for the procedure due to supply issues.”
2. use of sub-optimal medical equipment
“Using sub-optimal medical equipment poses an avoidable risk to patients of significant harm including death.”
Responses
2024-0359-Response-from-DHSC.pdf ↗· Department of Health and Social Care
Stated action · December 2019
“The NSDR has been in place since December 2019 and acts as a single point of contact when an NHS Trust is experiencing supply disruption and has not been able to mitigate the disruption. Once a disruption has been reported to the NSDR, the Department will then work to help resolve the matter, including by: - liaising with the manufacturer of the product in question for details of the disruption and any recovery plans; - contacting NHS Supply Chain or other distributors/wholesalers that stock the”
2024-0359-Response-from-NHSE.pdf ↗· Department of Health and Social Care
Stated action
“NHS England has engaged with Newcastle upon Tyne Hospitals NHS Foundation Trust on the concerns raised in your Report. We note that they state they were unable to determine the exact cause of the aortic cannula becoming dislodged, and that the default cannula choice was made for an operation of this nature. We note, however, that following [the deceased]'s death, the Theatre Department have permanently suspended use of the cannula.”