Archie Hames · Prevention of Future Deaths report

On 30/1/12 I opened the inquest into the death of Archie Hames, who at the date his death was 3 years old. The inquest was resumed and
concluded on 4/6/14.
I found that the cause of death to be:

1a – Cerebral hypoxia
1b – Airway obstruction (dislodged tracheal tube)
1c – CHARGE syndrome

I concluded with a narrative conclusion as follows:
On 15th January 2012 Archie Hames who was born with CHARGE syndrome and reliant on assisted respiration through a tracheostomy, was found unresponsive at his home address. Upon the arrival of paramedics he was resuscitated and taken to hospital, where he was found to have suffered irreversible brain damage and he succumbed and died of cerebral hypoxia on 19th January 2012. It is more likely than not that his tracheostomy device became dislodged when the attaching
Velcro strap caused wear and failure to the eyelet of the tracheostomy tube, causing it to fracture and work loose leading to cerebral oxygen starvation and death.

3 year old Archie Hames lived with his parents at their home address and he suffered from Charge Syndrome necessitating a tracheostomy in situ. He was at his home address on the morning of 15th January 2012 when his parents discovered that his tracheostomy tube was displaced and he was unresponsive. Upon the attendance of the paramedics he was resuscitated and taken to hospital where he was found to have suffered irreversible brain damage and he very sadly succumbed and died of cerebral hypoxia on 19th January 2012. It was subsequently found that the attaching Velcro strap to the tracheostomy tube had caused wear to its eyelet causing it to become detached causing airway obstruction and death.

• 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.