Margaret Erskin Hare Wakefield · Prevention of Future Deaths report

Margaret Erskin Hare Wakefield died on 5 February 2016 at the Royal Cornwall Hospital, Treliske, Truro and an inquest was opened on 11 February 2016. The inquest hearing took place on 3 October 2016. The inquest found an Open Conclusion with the cause of death recorded as 1a ischaemic heart disease 1b Severe Coronary Artery Atherosclerosis with stenting 4 February 2016 II Chronic Kidney disease.

Margaret Wakefield was admitted to the Royal Cornwall Hospital, Treliske, Truro on 16 January 2016 with chest pain and end stage renal failure (3x time a week dialysis). She was diagnosed with severe ischaemic heart disease with coronary artery stenosis together with diabetes, high blood pressure, peripheral vascular disease and unstable mental health (Bipolar Disorder). On 4 February 2016 she underwent rotational atherectomy and Percutaneous Coronary Intervention and an intra-aortic balloon pump was used to maintain her blood pressure. The procedure was challenging due to the extent of the stenosis but despite the drill becoming stuck, this was rectified and she was stabilised and transferred back to the ward. She was due to have her dialysis on the morning of 5 February, but she became unwell and unstable for haemodialysis. She instead required haemofiltration on the Critical Care Unit however there were no beds/staff available until 23:00 hours. Prior to a bed becoming available she developed chest pain and had a cardiac arrest. Despite resuscitation attempts she died that day as a consequence of her severe heart and renal disease. It was not clear whether to what extent the procedure or lack of availability of haemofiltration hastened her death.

Margaret Wakefield suffered from unstable mental health which on occasions meant she had lack of insight into her medical needs. It was recognised by both the Cardiac Surgeon and Renal Consultant that she was very unwell, the procedure was high risk and that she would require dialysis and that Critical Care haemofiltration may be required. Mrs Wakefield deteriorated quickly and when a request for haemofiltration (which was necessary and potentially lifesaving) was made it was not available in a timely way. The lack of haemofiltration resulted in further deterioration and death occurred before the facility could be made available.

The Consultant Surgeon and Renal Consultant both raised concerns as to the lack of haemofiltration for a patient with chronic renal disease following high risk heart procedure in a timely way, and the need for improved access to timely haemofiltration and contingency planning between the treating clinicians and Specialist critical care team.