Mr Thomas Smith Collings · Prevention of Future Deaths report

Mr Thomas Smith Collings, aged 64 years, died at Sunderland Royal Hospital on 2nd August 2018 at 2am from a naturally occurring illness contributed to by a combination of unexpected factors with regard to his life support. The Inquest, as part of my Investigation, concluded on 4th April 2019, when I recorded a conclusion ‘Natural Causes’.
The Cause of Death was: -
Ia Acute Myocardial Infarction
Ib Coronary Artery Disease
II Type 2 Diabetes, High Blood Pressure

Mr Collings suffered unheralded ventricular fibrillation (a lethal heart rhythm) at 01.20:41 on 2 August 2018, for which there was no warning – he was stable, symptom-free and all his observations had been good in the time leading up to the collapse. The ventricular fibrillation (VF) rhythm was very clear from the ECG traces and will have resulted in the cessation of effective cardiac output.

The ECG monitor showed a clear artefact after 01.21:00, which hid the true underlying rhythm, and after this time, it would have been impossible to determine that Mr Collings was in VF by looking at the monitor. He was undoubtedly in VF throughout this time however, until he was discovered 6-7 minutes later at around 1.27. VF does not terminate itself, and it was present when the crash team attached the monitor after commencement of resuscitation, so it was present throughout this time, and he would have remained without any cardiac output.

Lead disconnection is relatively common in sleeping patients (as well as those who are awake), for example when they roll over in their sleep, and so this pattern of artefact due to lead connection does not normally lead to urgent concern among nursing staff. This explained the pausing of the alarm before attending to Mr Collings.

Normally, abnormal rhythms such as VF are spotted quickly on a cardiac care unit when a nurse notices a patient collapse and checks their heart rhythm, or a nurse notices the abnormal rhythm on the ECG monitor, or the ECG monitor detects the VF rhythm automatically (the systems have algorithms to do this) and an urgent alarm is sounded. In Mr Collings' case, these usual processes did not occur.

There was an unfortunate combination of factors in Mr Collings' case that led to his death. It is likely that, if any one of these had not occurred, his death would have been averted on the balance of probabilities: -
• The occurrence of VF while the nurses were attending to other duties and not close to the central monitoring console.
• The ECG monitoring system did not detect the VF, and the red crisis alarm did not sound.
• Genuine artefact occurring 18 seconds later (likely as Mr Collings collapsed and detached an electrode), resulting in artefact on the ECG trace, when the nurses viewed the monitor.
• A confused patient being present on the unit at the same time, which diverted a nurse from attending to Mr Collings more quickly.

I should be glad to be told about any additional learning arising from the evidence heard at the Inquest especially with regard to the evidence of your engineer ████████ and
In particular, are there any improvements to the algorithm for earlier alerts, especially those that may differentiate sooner between any artefact, such as a detached lead, and a life-threatening event, such as a ventricular defibrillation, recognisable by the human eye?