Thomas Burroughs

12 Dec 2024 · Coroner Sonia Hayes · Essex

The coroner's concerns

1. split lumen of Hickman Catheter
“On 13 January 2024 acute Trust Hospital ward staff noted a split in the lumen of the Hickman Catheter and this was clamped and dressed”
2. lack of Datix for split Hickman Catheter
“The incident was escalated for urgent medical review due to the significant risk of infection, however no Datix was raised for the split Hickman Catheter as required by the acute Trust protocol”
3. delayed removal of Hickman Catheter
“Mr [name redacted] had a jejunal extension to his PEG on 15 January 2024. Advice was received that the Hickman Catheter should be removed as soon as possible if it was not being used”
4. continued use of Hickman Line despite signs of infection
“Mr [name redacted] was tachycardic and spiked a temperature on 19 January 2024 with no apparent symptoms of recurrent aspiration and the Hickman Line remained in situ”
5. removal of Hickman Catheter
“The Hickman Catheter was surgically removed on 30 January 2024”

Stated action

“have also retrospectively reported the incident to the Medicines and Healthcare Products Regulatory Agency (MHRA).”