Surrey Community Health

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First report 5 Jun 2014•Latest report 5 Jun 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Surrey Community Health linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Archie Hames · 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

    Three-year-old Archie Hames, who had CHARGE syndrome and relied on a tracheostomy, was found unresponsive at home on 15 January 2012 after the tracheostomy tube had become displaced. He was resuscitated and taken to hospital, but died of cerebral hypoxia on 19 January 2012; testing indicated that the attaching Velcro strap had worn the tube’s silicone eyelet, contributing to detachment and airway obstruction.

    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. The report was sent to Surrey Community Health; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure the integrity of tracheostomy tube attachments when using Velcro straps

    Wider context from the report

    “• Independent expert testing of the tracheostomy tube (model AMFNF-49) manufactured by Arcadia Medical and its attaching Velcro strap (model Trachi-Hold mini, TR ACC) manufactured by Kapitex Healthcare, confirmed that their combined use compromised the integrity of the silicone eyelet to the tracheostomy tube and was more likely than not to have caused the detachment of Archie’s tube • The further implications of such continued use • The implications of using Velcro strap attachments with other like tracheostomy tubes. I would ask that you consider give further consideration to the appropriateness of using Velcro strap attachments with tracheostomy tubes. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026