Stanley Alfred Babbs · Prevention of Future Deaths report

On the 25th April 2016 I commenced an investigation into the death of Stanley Alfred Babbs. The investigation concluded at the end of the Inquest on the 30th October 2020. The conclusion of the Inquest was a narrative conclusion:

Mr Stanley Babbs died as a result of the administration of IV contrast for a CT scan. An individualised, personal evaluation and assessment was not carried out before the administration of contrast. A robust risk/benefit analysis had not been carried out prior to the administration of contrast. Mr Babbs had not been informed of the risks of administration of contrast. Communication between the referring clinician and the radiology team was deficient. Had a personalised assessment, risk/benefit analysis and robust communication been carried out, on the balance of probabilities, the CT scan with contrast would not have been performed and his death at that time would have been avoided.

Mr Stanley Babbs was 91 years old. He had a past medical history of chronic kidney disease (stage 4), diabetes and heart failure. He had been generally well in 2015 but was noted on blood tests to have a low haemoglobin. His haemoglobin was within the target range for a patient with chronic kidney disease. Mr Babbs was referred to a gastroenterologist by his general practitioner. The gastroenterologist considered that a CT scan would be required to exclude a possible malignancy. Other than the chronically low haemoglobin, there were no other clinical indicators of malignancy. The CT scan was requested and a radiologist agreed that a contrast CT scan could take place, with appropriate hydration being administered. On the 21st January 2016 a contrast CT scan took place. Following this Mr Babbs became unwell and blood tests taken on the 25th January 2016 showed a very raised creatinine. He was diagnosed with a contrast induced acute kidney injury and admitted to hospital. During hospitalisation he required a catheter. Sadly, he succumbed to sepsis from a urinary tract infection and passed away in hospital on the 16th February 2016.

The Royal College of Radiologist Standards for Intravascular Contrast Administration requires that the ultimate responsibility for intravascular contrast administration rests with the person who prescribes it.

The Standards identify risk factors for acute kidney injury, to include chronic kidney disease (eGFR of less than 40); heart failure and age 75 years or older. The Standards identify that for those at risk of acute kidney injury, the dose of non-ionic iodine based contrast medium should be minimised, taking into consideration the indication and patient's body weight.

It was noted at the Inquest hearing that a Practice Group Direction has been prepared for the administration of contrast to persons who are not at increased risk (those with an eGFR greater than 30). There is no such Practice Group Direction or other prescribing safeguards for patients at higher risk (eGFR lower than 30).

The clinical lead for radiology at the Trust stated in his oral evidence that there is no prescription for contrast. This is so, even though contrast is a prescription only medicine. The clinical lead stated that a radiologist will simply say “contrast” or “no contrast”. This is the case even for those patients who have a high risk of a contrast induced acute kidney injury.

Patients with chronic kidney disease, diabetes, cardiac failure and aged over 75 have an up to 25% risk of a contrast induced acute kidney injury. In these circumstances, it is concerning that contrast media (a prescription only medicine) can be administered without a formal prescription, evidence of a careful consideration of the dose and a clearly identified responsible clinician.