Mrs Ashana Charles · Prevention of Future Deaths report

An investigation was opened on 28th November 2018 into the death of Mrs Ashana Charles on 20th November 2018 in Queen Elizabeth Hospital, Woolwich. The inquest was part heard in London Inner South by me as senior coroner on 13th February 2020. Following alarming evidence first heard in court, the pathologist recommended investigations and expert evidence that required international searching, which was not completed before I fell ill and retired from London Inner South. In December 2024 the case was transferred to South London. The resumed inquest concluded on 9th December 2025. The conclusion of the inquest was that she died from acute obstruction of small pulmonary arteries by cellulose fibres, which had embolised from inadvertently contaminated intravenous infusions at some stage of product preparation or administration. The source of fibres could not be identified, but the sudden death from embolism would have been prevented had a 1.2 micron filter been used in IV infusion, which was not standard practice at the time.

Mrs Charles was admitted to hospital in September 2018 with weight loss and anaemia from severe immunosuppressed advanced stage AIDS. She improved on retroviral therapy and treatment of complications, including CMV colitis, but she had persistent diarrhoea and hypoalbuminaemia requiring parenteral feeding. A Hickman line was inserted on 14/11, Ganciclovir was begun and IV antibiotics continued. At 22.30 on 19/11 IV feeding was begun with Nutriflex Omega Special, to which vitamins had been added by the manufacturer. The standard giving set normally used on the ward would have had an integrated 15-micron filter. There was no record of deviation from routine aseptic technique in administration. On the morning of 20/11, she was clinically improved on review; a hot feeling was sensed when medication was infused, but she had no temperature. At 13.55 her unexpected cardiac arrest was witnessed and CPR begun immediately. She was declared dead at 14.36.

1. That no source of contamination could be identified due to the infusion set, filter, feeding bag and lines not being retained for forensic investigation. The pathologist Professor ████████ gave an opinion that deaths that might be associated with IV feeding were probably underreported due to inadequate investigation.

2. ████████, expert pharmacist and pharmaceutical regulator drew attention to
a) The inconsistency at the time between US and European and UK guidance about use of filters in parenteral feeding (PN).
b) Reference to filters for Omega Special by the drug manufacturer at the time indicating an appropriate filter “if one was used”, but not its need or desirability or context of use, and the value of manufacturers and health providers integrating their approach to risk management.
c) The use of the 1.2 micron filter at the time was not standard practice, perhaps because of cost or operational reasons as the filter often led to blockages and delays in IV feeding. Now both that BNPG guidance and B Braun recommend the use of 1.2 micron filters on Omega Special label, but that does not give assurance that all PN and filter manufacturers issue the same guidance nor that their products are operationally consistent with guidance.
d) Lewisham & Greenwich NHS Trust have begun to re-evaluate the use of 1.2 micron filters in PN feeding but the matter had not yet gone to its governance department but should do so next year. There was a need for those responsible for decision implementation in hospitals nationally to cross work with manufacturers and specialist bodies.
e) Uncertainty whether the reported visual checks of PN products by batch rather than individually provided adequate safety assurance.