17 Jan 2023 Teegan Marie Barnard · Prevention of Future Deaths report West Sussex
View report summary
Concerns raised 1
Failure to consider and exclude tension pneumothorax during PEA cardiac arrest View source
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Association Of Anaesthetists (Great Britain & Ireland) NHS England Royal College of Anaesthetists University Hospitals Sussex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
University Hospitals Sussex NHS Foundation Trust
Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
View source
University Hospitals Sussex NHS Foundation Trust
Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
View source
University Hospitals Sussex NHS Foundation Trust
Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
View source
University Hospitals Sussex NHS Foundation Trust
Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
View source
Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
View source See 3 more actions
×
AI-generated summary
Teegan Marie Barnard · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Teegan Marie Barnard suffered a prolonged PEA cardiac arrest during emergence from general anaesthesia after an emergency caesarean section, following significant postpartum haemorrhage and bilateral tension pneumothoraces. She sustained a non-survivable hypoxic brain injury and died at home six weeks later. Concerns included failure to consider and promptly recognise tension pneumothoraces during resuscitation, and inadequate investigation, clinical governance and learning after her death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to consider and exclude tension pneumothorax during PEA cardiac arrest
Wider context from the report “1. Resuscitation algorithm (4 H’s & 4 T’s)* for PEA cardiac arrest
I heard evidence that the 4 H’s and 4 T’s should be considered and excluded in any PEA cardiac arrest situation . Steps were taken to treat anaphylaxis, but in the absence of any improvement in Teegan’s clinical condition, and whilst it was mentioned, no steps were taken to exclude possible bilateral tension pneumothoraces . Evidence was heard at the Inquest that it is the only one of the 4 H’s and 4 T’s (see footnote) that directly results in a sudden inability to ventilate, with the HSIB report indicating that there was sufficient time to consider and exclude this possibility given the length of time of the PEA cardiac arrest.
” Source location Teegan Marie Barnard · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide multidisciplinary training for obstetric, anaesthetic and midwifery staff covering obstetric emergencies, maternal collapse and the 4H’s and 4T’s.
Verbatim wording from the response “However, the Trust recognises that for staff to perform optimally in extremely challenging situations such as maternal cardiac arrest appropriate training is essential. The Trust has therefore taken action to ensure all the appropriate members of the Multi-Disciplinary Team (MDT) have received the necessary training to be able to manage obstetric emergencies. An audit conducted in January 2023 demonstrates that over 90% of the obstetric, anaesthetic and midwifery staff that work within the labour ward environment across the entire organisation had received this MDT training. This reaches the stringent standards set for training by the Clinical Negligence Scheme for Trusts year 4 requirements. Of note maternal collapse has been a scenario within the training program since the beginning of the year and includes reference to the 4H’s and 4T’s.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Include tension pneumothorax and surgical emphysema management in regular anaesthetic trainee simulation sessions.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and deliver simulation demonstrations of national anaesthetic Regulation 28 notices through teaching and clinical governance meetings.
Verbatim wording from the response “b. Inclusion of the management of tension pneumothorax in the regular SIM sessions for the anaesthetic trainees at St. Richard’s Hospital. This includes the significance of facial swelling and surgical emphysema. The trainers are planning SIM demonstrations of all the national anaesthetic regulation 28 notices and will play the recordings at teaching and clinical governance meetings.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review guidance on managing increased airway pressure in ventilated patients, including its relevance to surgical emphysema and tension pneumothorax.
Verbatim wording from the response “c. The Trust’s anaesthetists have carefully reviewed The Royal College of Anaesthetists (RCA) guidance on the management of increased airway pressure for the ventilated patient which forms part of their Quick Reference Guide to Anaesthetic Emergencies Quick Reference Handbook (QRH) | The Association of Anaesthetists. Although the current handbook does not refer to surgical emphysema or tension pneumothorax in the management of increased airway pressures, we also note that, in their response to the PFD, the RCA and AA will share the learning that bilateral pneumothoraces can be a cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery-through the SALG’s Patient Safety Update.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Verbatim wording from the response “Bilateral pneumothoraces occurring on emergence from a general anaesthetic, especially one for surgery that did not include thoracotomy or thoracoscopy, is so rare that most anaesthetists will never encounter such a situation. All anaesthetists are taught the 8 reversible causes of cardiac arrest through the Resuscitation Council’s Advanced Life Support course, or an equivalent, that they must complete as part of their training and maintain their competencies throughout their career. Bilateral pneumothoraces are mentioned only in the setting of trauma in the Resuscitation Council’s guidelines. For this reason, we will share the learning from Teegan’s death that bilateral pneumothoraces can be cause of failure to ventilate leading to cardiac arrest in the absence of trauma or thoracic surgery.” Source location Response from Royal College of Anaesthetists
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that the team unreasonably delayed identifying tension pneumothorax or surgical emphysema during the cardiac arrest.
Verbatim wording from the response “You have raised concerns that although there are 8 contributory causes of Pulseless Electrical Activity (PEA) cardiac arrest (the 4H’s and 4 T’s), only one of these, tension pneumothorax, also causes a sudden inability to ventilate a patient; it was therefore determined that there was a delay in the team identifying this as the cause of the PEA arrest. Concern has also been raised that there was a delay in the team identifying surgical emphysema despite the presence of indicative signs.” Source location Response from St Richards Hospital
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The existing ALS course adequately covers the resuscitation algorithm and cardiac arrest in pregnancy, so no course change is required.
Verbatim wording from the response “NHS England also consulted with the Resuscitation Council UK as part of its review of your Report. It should be noted that as a result of Teegan’s death, the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.” Source location Response from NHS England
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Verbatim wording from the response “I write in response to your report of 17 January 2023, made under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I have been asked to respond on behalf of Health Education England. Please may I start by offering my sincere condolences to the family of Teegan Marie Bernard, following her tragic death. However, having carefully considered the report, together with the facts of the case, we believe that whilst there are valuable lessons to be learned; Unfortunately, these do not come within the scope of HEE’s current role and statutory responsibilities.” Source location Response from Health Education England
Open published response
15 Jun 2017 Mr Kevin George Mann · Prevention of Future Deaths report East London
View report summary
Concerns raised 1
Failure to avoid the swallow procedure in the presence of a left pneumothorax View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Mr Kevin George Mann · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mr Kevin George Mann underwent an Ivor Lewis procedure for oesophageal cancer and subsequently developed a pneumothorax. A Visipaque contrast study was performed despite the pneumothorax, and contrast entered his left main bronchus; his respiratory condition deteriorated and he later died. Concerns included failures to check available imaging and an outstanding chest x-ray request, to stop the procedure when contrast entered the bronchus, and to document the amount of contrast used.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to avoid the swallow procedure in the presence of a left pneumothorax
Wider context from the report “1. 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 .
” Source location Mr Kevin George Mann · Prevention of Future Deaths report
Open source report
Concerns raised 2
Conservative management of left pneumothorax with antibiotics View source Failure to insert a chest drain for pneumothorax View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Herbert Chandler · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Conservative management of left pneumothorax with antibiotics
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics ,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” Source location Herbert Chandler · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to insert a chest drain for pneumothorax
Wider context from the report “A series of failings by the Trust have caused or contributed to the cause of death, namely:-
• A conservative approach to managing the left pneumothorax with antibiotics,
• Inappropriate prescribing of medication, namely gentamicin and aminophylline,
• A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician,
• A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team,
• The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray,
• The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung,
The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology,
• A confusing format of medical records which prevented sequential recording of entries by health care professionals,
• A failure to provide Consultant on call respiratory cover.
” Source location Herbert Chandler · Prevention of Future Deaths report
Open source report
14 Oct 2013 Frederick Davidson · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 2
Delays in medical treatment following pneumothorax View source Failure to recognise pneumothorax on X-rays View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Frederick Davidson · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Delays in medical treatment following pneumothorax
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment .
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Source location Frederick Davidson · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to recognise pneumothorax on X-rays
Wider context from the report “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate.
• The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures
• Unexplained and important gaps in the clinical notes
• Breakdown in communication between the junior doctor and consultant.
• The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment.
• The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation.
• Delay in the forwarding and receipt of x ray reports from radiology
” Source location Frederick Davidson · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.