Patrick Stephen Moran · Prevention of Future Deaths report

On 2 August 2018 I commenced an investigation into the death of Patrick Stephen Moran, aged 70. The investigation concluded at the end of the inquest on 5 January 2018. The conclusion of the inquest was death by natural causes from multi organ failure due to iliac artery rupture (operated), due to severe peripheral vascular disease, with underlying osteoporosis and pulmonary hypertension

Mr Moran was admitted acutely to the Royal Free on 25 July having been seen at the vascular clinic at UCLH on 20 July 2017 due to ongoing leg pain with left foot gangrene on the tips of his toes and chronic peripheral vascular disease.

He was expedited urgently to theatre where an angiography and angioplasty of the left iliac system was performed under local anaesthetic. During the procedure he suffered an iliac artery rupture, which was successfully treated. He initially made good clinical progress. However, the left lower limb became non-viable and an above knee amputation performed. His right lower limb then deteriorated and it was agreed that the collective morbidity meant that further interventions would be futile.

(1) During the procedure under local anaesthetic on 25 July 2017 Mr Moran continued to bleed due to the unknown existence of the rupture at that time. He developed hyperkalaemia and was administered an insulin-dextrose infusion. He was to be infused 10 units (0.1ml) on insulin but was mistakenly infused with 100 units (1ml). The serious incident investigation identified that the ST4 Anaesthetist did not use an insulin syringe but instead used a normal 1ml syringe. The use of this syringe was common practice within the anaesthetic department in spite of the issue of alert NPSA/2010/RRR013.
(2) Since 2010 diabetes was removed from the mandatory training requirements across the organisation. As a result there is currently no mandatory training provided to doctors within the Trust to advise them of use of insulin specific devices when drawing up and administering insulin. It is apparent from the action plan that emails have been sent to Consultant Anaesthetists in this regard.
(3) There is currently no process across the organisation to review continued compliance with CAS alerts and ensure that changes made across the Trust still reflect the requirements of previously issued alerts.