Boycie [Alexander/Chatterton] · Prevention of Future Deaths report

An investigation was commenced into the death of Boycie [Alexander/Chatterton], aged 6 weeks. The investigation concluded on 1 September 2023. The conclusion in the inquest was:

Complication following surgical procedure

The medical cause of death was

1a Hypoxic-ischaemic brain injury
1b. Multiple respiratory arrests
1c. Complications following oesophageal atresia and tracheo-oesophageal fistula repair procedures.
2. VATER association.

B was born at 36 weeks and 6 days gestation. At birth B was was diagnosed with congenital abnormalities including Oesophageal Atresia (OA) and Tracheo-Oesophageal Fistula (TOF), a condition denoted by a blind-ending upper oesophagus with the lower oesophagus connected to the trachea, which affects about 200 babies a year in England. B had an initial surgical procedure to disconnect the TOF and join the oesophagus, but the gap between the two parts of the oesophagus was too great at that time to join. This is known as long gap Oesophageal Atresia (OA), a condition which affects about 20 babies a year in England. Management of long gap OA is very significantly more challenging than non-long gap OA. There are different options for treatment of long gap OA. In this case the surgical team applied tension sutures to draw the oesophageal ends closer for later joining. B had a second planned surgical procedure to check whether the oesophagus was capable of being joined and it was not. At the third planned surgical procedure, an oesophageal anastomosis was performed. Following the third surgical procedure, B developed respiratory complications as a result of which he died.

1. I heard from experts giving evidence that the treatment of conditions such as OA with or without TOF would be better served by a properly managed and funded national register for TOF cases, which would in their view likely serve to improve outcomes and survival rates going forward.