Search

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

Archant

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.”

Latest East London News Stories

17:43

MPs opposing the Brussels Brexit deal joined campaigners converging on east London for today’s rally at the Excel centre calling for a People’s Vote on the controversial agreement being debated in Parliament on Tuesday.

13:00

Thousands campaigners are converging on east London this afternoon for a rally calling for a People’s Vote on Brexit ahead of Tuesday’s crucial vote in Parliament.

08:00

Letters, contributions and comments sent in to the Advertiser this week.

Brexit continues to dominate the political landscape and Tower Hamlets Council deserves praise for setting up its own commission to examine the potential economic and social impact that leaving the EU will have on the borough.

Fri, 19:00

Mobility scooter and wheelchair users can receive free advice on staying safe while travelling on the Docklands Light Railway (DLR).

Fri, 14:25

Cinderella has brought the Christmas panto season to Mile End amid the eternal battle with her Ugly Stepsisters.

Fri, 12:02

Researchers from Queen Mary University have helped create the Xingu Village installation taking visitors to the heart of Brazil’s native communities.

Fri, 12:00

Tower Hamlets has lost 75 pubs although more people are working in the trade, figures have revealed.

PROMOTED CONTENT

Are you a landlord looking for a fixed rental income, paid whether the property is empty or not? Steve Westley, general manager at estate agents Elliot Leigh, explains their Guaranteed Rent Scheme and how it takes the stress out of letting your property.

Newsletter Sign Up

East London Advertiser twice-weekly newsletter
Sign up to receive our regular email newsletter

Our Privacy Policy

Most read news

Hot Jobs

Show Job Lists

Digital Edition

cover

Enjoy the
Docklands and East London Advertiser
e-edition today

Subscribe

Education and Training

cover

Read the
Education and Training
e-edition today

Read Now