Patricia Cragg · Prevention of Future Deaths report

On 6 February 2017, I commenced an investigation into the death of Patricia Cragg, then aged 74. The Inquest concluded at the end of the Inquest on 23 August 2018. The conclusion of the Inquest was that Mrs Cragg died from a known but rare complication of a necessary medical procedure.

The medical cause of death was given as:-
1a) Haemorrhage into Retro Peritoneum (Right Iliac Artery Haemocoele Device appropriately placed)
1b) Angiogram/Angioplasty
1c) Unstable Angina from Severe Three Vessel Coronary Artery Atherosclerosis
II)

Mrs Cragg had severe coronary artery disease. She was not felt to be a suitable candidate for surgery. On 26 January 2017 she underwent a high-risk percutaneous interventional guided by intravascular ultrasound carried out by ████████ At the end of the procedure, the patient reported pain and it was suspected that she was bleeding from the arterial point of entry. The decision was quickly made that she required a CT scan to confirm the diagnosis. Unfortunately, as a consequence of an unrelated road traffic collision, there were a number of other patients also awaiting a CT scan. It took hours for Mrs Cragg's CT scan to be performed which revealed an extensive haemorrhage. Before she could be taken to theatre she deteriorated and died in the hospital on 27 January 2017. It was accepted at inquest that earlier surgical intervention may have prevented the outcome although in the context of a number of other significant comorbidities.

(1) There was a lack of available CT resource to deal with the two simultaneous sets of emergencies. The inquest heard from ████████ who accepted this had been recognised weakness for a considerable period of time. I was advised that there were two potential courses of action that could be adopted to overcome this difficulty. First, there could be a second on-call consultant radiologist available to assist the first on-call consultant at times of particularly high demand. Secondly, there could be a facility to open up and run a second CT scanner. This would require the presence of the whole range of staff to include radiographers, porters, et cetera. I was told this was the second time in recent years where there had been simultaneous emergencies that inevitably meant there was a delay in reporting a patient's condition. It seems a decision is required as to whether it is appropriate to allocate additional resource to CT imaging and if so how that additional resource should be deployed in times of unexpected high demand.

(2) I was told that the radiology department did not have its own internal major incident policy setting out how to respond to situations like that involving Mrs Cragg. ████████ informed me that this was a piece of work he was trying to complete but that he would need input and assistance from his consultant colleagues before being able to do so.