Peter Jason FANNING · Prevention of Future Deaths report

On 8 January 2024 I commenced an investigation into the death of Peter Jason FANNING. The investigation concluded at the end of the inquest. The conclusion of the inquest was; Natural causes

Peter was born with cerebral palsy which caused severe physical impairment. He communicated using a liberator device and received a full package of care at home. He was fed using a gastrostomy tube with a jejunal extension which became dislodged periodically and he suffered from epilepsy and episodes of aspiration pneumonia. In 2022 and 2023 there were repeated dislodgments of his feeding tube resulting in him being admitted to hospital for replacements which impacted on his nutritional state and frailty. He was admitted to the Birmingham Heartlands Hospital on 07/11/23 after a further dislodgement of his feeding tube which was replaced on 15/11/23 due to there only being one radiology list per week for complex feeding tube replacements. He was discharged home on 18/11/23. The feeding tube dislodged again requiring further admission on 24/11/23. The tube was reinserted on 28/11/23 but unfortunately became dislodged again on 30/11/23. Peter was treated for severe pneumonia on 30/11/23. A PICC's line was inserted on 05/12/23 to provide total parenteral nutrition until a further more permanent feeding tube could be inserted surgically on 13/12/23 but this PICC line also dislodged on 07/12/23 and had to be replaced on 11/12/23. Peter deteriorated with further symptoms of pneumonia on 15/12/23 and sadly died on 19/12/23.

Following information from the Deceased’s treating clinicians the medical cause of death was determined to be:

1a Pneumonia

1b Frailty

1c

II Epilepsy, Cerebral Palsy

1. The inquest heard evidence that there is only one radiology list per week to accommodate replacement of feeding tubes in patients with complex needs. In Peter’s case this meant he had to wait a week for the tube to be replaced meaning he had suboptimal nutrition during this period. Consideration should be given to whether additional services are required for replacement of feeding tubes in patients with complex needs.

2. The inquest heard evidence that Peter’s nutritional status was suboptimal due to repeated tube dislodgments and waiting for radiology or theatre slots to be available. Consideration needs to be given as to how best to maintain patients’ nutrition after tube dislodgments when they rely on feeding tubes.