Ivan Merryfield O’Neill · Prevention of Future Deaths report

On 22nd April 2020 I commenced an investigation into the death of Ivan Merryfield O’Neill aged 74 years. The investigation concluded at the end of the inquest on 20th November 2020. The conclusion of the inquest was a narrative conclusion:

“On 21st April 2020 Mr Ivan Merryfield O’Neill attended hospital for dialysis. An accidental dislodgement of a venous needle that takes blood under pressure to the dialysis machine occurred, which led to a significant bleed. Staff on the unit were unaware of the bleed, until an alarm from the dialysis machine sounded due to a drop in pressure. Mr O’Neill was found to be unresponsive having sustained a cardiac arrest due to hypovolemic shock, despite resuscitation attempts his life was pronounced extinct at 09.30 hours.”

The cause of death was recorded as;
1a; Hypovolemic Shock
1b; End-Stage Kidney Disease
II; Polyneuropathy, Frailty and COVID19

During a regular dialysis appointment, Mr O’Neill bled to death when a venous needle became dislodged from the site of his arteriovenous fistula.

1. Mr O’Neill was known to be a restless patient during a dialysis session. This factor must have increased the risk of needle dislodgement.
2. Mr O’Neill was a frail patient with little reserve and would be more likely to swiftly lose consciousness following a bleed.
3. Mr O’Neill was placed in a position which was outside of a clear line of sight from the nurses station.
4. The automatic alarm triggered by the dialysis equipment was insufficiently sensitive to promptly alert staff to a bleed until between 200 – 2000 mls of blood had already been lost.