Hospital changes post-surgical care following man’s death

PUBLISHED: 07:00 27 June 2018

Royal London Hospital. Picture: Mike Brooke

Royal London Hospital. Picture: Mike Brooke


A hospital has changed the way it carries out post-surgical care following the death of a man after a routine operation.

The Royal London Hospital was issued with a prevention of future deaths report in relation to the death of Mike Fell, 65, at the hospital in the early hours of October 27 last year.

Poplar Coroner’s Court heard how Mr Fell had an elective aortic aneurism repair at the Whitechapel Road hospital the day before his death.

After surgery, he was transferred to the adult critical care unit whilst sedated and ventilated with a trauma line, which had a three way tap connected.

Around three hours later, he went into cardiac arrest, and it was noted that the tap was set as ‘open to air’.

A scan revealed he had suffered a bleed on the brain as well as air in his brain, liver and kidneys, which he was unable to survive.

Assistant coroner Sarah Bourke ruled that the “air embolism was most likely to be the result of the three-way tap on the trauma line being ‘open to air.

She gave a narrative verdict, stating that Mr Fell’s death was as a result of an intercerebral haemorrhage and a cerebral air embolism, as well as being connected to the surgery.

She also recommended that action be taken by Barts Health NHS Trust, which runs the hospital, to prevent future deaths.

She said: “Whilst it is a matter of routine care to check that unused taps are ‘closed to air’, it is not recorded in Mr Fell’s notes that hte taps had been checked and were closed. It is unclear how or when the three-way tap on the trauma line became open to air.”

Ms Bourke added: “The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed.”

A Barts Health NHS Trust spokesperson said: “We are very sorry for the tragic circumstances that led to Mr Fell’s death while he was in our care.

“Unfortunately, the coroner’s investigation has been unable to determine the exact cause of the three-way tap being open, however as a trust we take full responsibility and have held a thorough investigation to ensure we learn from this tragic incident.

“We have learned from this tragic incident and conducted a review of our trust protocols. As a result we no longer use three way taps in these clinical areas.”

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