Margaret Elizabeth Clark · Prevention of Future Deaths report

On 6ᵗʰ November 2017 I commenced an investigation into the death of Margaret Elizabeth Clark aged 75. The investigation concluded at the end of the inquest on 6ᵗʰ February 2018. The conclusion of the inquest was that Margaret Elizabeth Clark died from a rare but recognised complication of surgery.

Margaret Elizabeth Clark suffered an oesophageal tear in the course of a transoesophageal echocardiogram [“TOE”] carried out at Blackburn Victoria Hospital on the 9ᵗʰ May 2017. She was transferred to Royal Preston Hospital, where the tear was repaired, but she died of sepsis which developed as a result of the tear, on the 12ᵗʰ August 2017.

I was told that in 2017 the types of probes used for TOEs were changed, to a design which required covering with a sheath. Using that sheath, three fatal oesophageal tears had occurred in the space of 5 months, involving in each case experienced anaesthetists who had conducted TOEs routinely for many years without event. [I was told that there had been one previous incident in the preceding 16 years]. The sheaths used – Ecolab Ultracover for TEE – were replaced at Blackpool Victoria Hospital with alternative [softer] sheaths – Probetecion TOE/TEE Transducer Kit. Since the replacement sheaths have been used, there have been no incidents of tear. I was told that the Ecolab sheaths may still be used in other hospitals and Trusts. A Serious Incident Investigation Report expressed a concern that the tears may have resulted from the use of the Ecolab sheaths, which [it was felt] created more resistance on insertion than had been the case before their use.
(1) I believe you should review the use of the Ecolab sheaths and consider whether they should not be replaced in all hospitals and Trusts by the Protec[tion] sheaths.