Richard Nigel KEW · Prevention of Future Deaths report

On 15 September 2022 I commenced an investigation into the death of Richard Nigel KEW aged 70. The investigation concluded at the end of the inquest on . The conclusion of the inquest was that:

Mr Kew was admitted to the Glenfield Hospital Leicester and underwent a resection of small bowel endocrine tumour with extensive lymphadenectomy and resection of multiple liver metastases on the 21 July 2022. Immediately post-operatively he was admitted to the adult Intensive Care Unit. During mobilisation of Mr Kew on the 22 July there was an inadvertent omission to secure one of the central venous catheter lines with a bung. This omission allowed air entrainment into Mr Kew’s circulation. His condition deteriorated rapidly and whilst he received immediate senior medical attention, he never regained consciousness and died as a direct result of the consequences of the omission on the 05 September 2022.

As above with a cause of death as
1a) Diffuse Hypoxic Brain Injury
1b) Air entrainment via a central venous catheter
1c) Peri-operative requirement for physiological support
1d) Ileocolic anastomosis and resection of liver metastases to treat small bowel neuroendocrine tumour and multiple liver metastases

That whilst the University Hospitals of Leicester(UHL) have taken adequate and acceptable steps following this incident to prevent this occurrence ever happening again. In particular the UHL have now adopted a policy of having bionectors at the end of patent lines instead of relying upon a simple bung and particular training for nurses in the correct and safe way to ensure safety of the lines whilst moving patients ensuring that this aspect has become a specific competency in training. However, I am concerned that other Trusts may not have such policies and procedure in place to prevent the inadvertent error of not capping a patent line of a central venous catheter during the mobilisation of a patient.