Craig John BURFIELD · Prevention of Future Deaths report

On 18 September 2023 I commenced an investigation into the death of Craig John BURFIELD. The investigation concluded at the end of the inquest on 26.03.24. The conclusion of the inquest was

Craig Burfield died on 24.02.23 at the Northern General Hospital Sheffield from the consequences of clots which formed in his hydrocephaly shunt and cerebral sinus during surgery related to his spina bifida. This caused his brain to swell in an unsurvivable event. The cause of the blood clots could not be established on the evidence.

1a Cerebral oedema and Coning

1b Cerebral Sinus and Ventriculo-Cardiac Shunt Thrombosis

1c Spina-Bifida (Previously treated)

II

Craig Burfield suffered from spina bifida and had shunts fitted as a child. He had complicated medical needs as a result of his condition. He was admitted for surgery for bladder stones at the spinal injury unit at the Northern General Hospital on 20.02.23, undergoing surgery on 23.02.23. He failed to come round from the anaesthetic and died from swelling in the brain as set out above. The cause of the thrombosis could not be established.

During evidence from the family and ████████, author of the internal investigation, it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult. Also, there was no process for review of patients such as Craig.

████████ gave evidence that there remained no transfer protocol or pathway in place as children move into adulthood as at the current date nor an effective review process for adults at the present time. In evidence she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.