Donald John TILL · Prevention of Future Deaths report

On 17/01/2017 I commenced an investigation into the death of Donald John TILL. The investigation concluded at the end of the inquest on 11th January 2018. The conclusion of the inquest was that the deceased was a 68 year old man with a history of small bowel adenocarcinoma treated by surgery and chemotherapy in 2014. He presented to the Accident and Emergency department at the Royal Stoke University Hospital, Stoke-on-Trent on the 2nd January 2017 with a history of abdominal pain and vomiting. A CT scan showed a large bowel obstruction and a primary sigmoid colon cancer was suspected. He underwent emergency laparotomy on the 4th January 2017. He had been kept nil by mouth on the day of the surgery. Previous anaesthetic charts were not available prior to the induction of anaesthesia. He was anaesthetised in theatre whilst in his ward bed. A number of co-morbidities made him a high risk patient; he suffered from obstructive sleep apnoea, using a continuous positive airway pressure machine at night (CPAP); he had prominent front tooth crowns and a limited degree of mouth opening; the presence of a small beard and an elevated BMI. A clinical decision was made not to use cricoid pressure. An epidural was administered and he was then positioned in a head up, ramped position for anaesthesia. He was pre-oxygenated and anaesthetised using Fentanyl, Propofol and Atracurium induction agents. Immediately after he had received them he vomited large amounts of faeculent material. His ward bed did not rapid tilt so he was placed head down over the edge of the bed to try to avoid contamination of the lungs. It was apparent that aspiration had occurred. A bronchoscope was sourced from thoracic theatre, initially the suction button was missing but this was found and bronchiolar lavage was done using saline to wash contaminated lungs. A nasogastric tube had not been inserted prior to anaesthetic but was inserted during the procedure. Antibiotics were administered intravenously. In view of the surgery required a decision was made to proceed. Multiple lesions were found and the bowel was resected. He was transferred to the intensive care unit where he continued to deteriorate and he died at 11.30am on the 5th January 2017. The cause of death given after post mortem examination was
1a Aspiration pneumonia.
1b Intestinal obstruction.
1d Adenocarcinoma of sigmoid colon (operated on 4.1.17).

Admitted 2/1/17 with abdominal pain and vomiting, A CT showed large bowel obstruction. On 4/1/17 a laparotomy, bronchoscopy and limited right hemicolectomy were undertaken. History: small bowel cancer resection for cancer in 2014 followed by chemo, inguinal hernia repair.

1. The deceased’s previous medical records were not available. Different clinical decisions might have been made had they been available.
2. The deceased was anaesthetised on a ward bed and it would have helped if he had been on a trolley with rapid tilt.
3. A bronchoscope was not part of the standard anaesthetic equipment trolley and when one was sourced it had a suction button missing.
4. Cricoid pressure and NG tubes were not used in this case.