Sangeerth GIRIRATHAN · Prevention of Future Deaths report

On 16 December 2021 I commenced an investigation into the death of Sangeerth GIRIRATHAN aged 23. The investigation concluded at the end of the inquest on 06 May 2022. The conclusion of the inquest was a narrative one as follows:

The deceased was involved in a road traffic collision on the 23rd of October 2021 on the M1 motorway in Milton Keynes between Junction 13 and 14 and suffered a traumatic brain injury. Whilst in Milton Keynes University Hospital on the intensive care unit he suffered an anoxic cardiorespiratory arrest due to a blockage of his tracheostomy tube that went unrecognised because the alarm on the monitor was switched off. The delay in recognising the blockage resulted in a lost opportunity to intervene earlier that would have prevented his death. He died on the 12th of December 2021.

See above narrative.

During the inquest it became apparent that the alarms that are operating on the monitors had been disengaged. This resulted in the staff not being alerted when the patient’s saturations fell below an acceptable level and he went into cardiac arrest. My understanding is that if a patient is being monitored at all then it is essential that the alarms remain operational. I believe that all staff should be reminded of the need for the alarms to be active so that future deaths in similar circumstances do not arise.

During the course of the inquest it became apparent that the deceased, who was employed as a delivery van driver, had been working for long hours prior to the original collision. It is likely that he may have fallen asleep and collided with the back of a stationary lorry on the M1 motorway. I am told that there are currently no regulations regarding the hours that can be worked by a van driver as opposed to the regulations that operate for heavy goods vehicles. I believe that this is a matter that should be reviewed by the department in order to prevent similar deaths in similar circumstances.