Patricia Lilian Parker · Prevention of Future Deaths report

On 10th January 2017 I commenced an investigation into the death of Patricia Lilian Parker, aged 89. The investigation concluded at the end of the inquest on 11th July 2017. The conclusion of the inquest was a Narrative conclusion:
The deceased underwent an endoscopic procedure under sedation at Milton Keynes Hospital on 5th January 2017. She suffered a cardiac arrest following sedation and despite resuscitation she died at 04.15 on the 8th January 2017.

The medical cause of death was recorded as 1(a) Hypoxic brain injury following cardiac arrest during diagnostic endoscopy 2) Gallstones, Atrial Fibrillation.

On 5th Jan 2017 the deceased was prepared for an endoscopy. Her throat was sprayed with Xylocane she was then given Midazolam ████████ and Pethidine ████████ and the procedure was started. Her saturations dropped suddenly and she became cyanosed, the procedure was immediately stopped but she went into cardiac arrest. CPR was started, she was intubated and admitted to Department of Critical Care for further management. Her family were informed of the situation and the possible cause of arrest was likely to be due to her sedation prior to endoscopy. She died on 8th January 2017. There was a failure to adhere to the Trust's Intravenous Sedation Policy for adults and BNF (British National Formulary) recommendations in relation to titrating of the sedation.

(1)That the numerous guidelines relating to the use of sedation should be more widely brought to the attention of all clinicians undertaking sedation.
(2) That NHS England should highlight the problems arising from the use of sedation particularly in the elderly and encourage all Hospitals to develop training locally for their clinical staff.