Patricia Steer · Prevention of Future Deaths report

On 14 December 2015 commenced an investigation into the death of Patricia Steer aged 81 years. The investigation concluded at the end of the inquest on 10 May 2016. The conclusion of the inquest was that she died after the clamp was briefly left open on a central venous catheter port resulting in air embolization and cerebral infarction.

On 1 June 2015 Mrs Steer was admitted to the Homerton Hospital for an elective right sided total knee replacement. She made a good recovery and was discharged on 8 June. On 11 June she returned to hospital unwell with sepsis, which was treated effectively using a central venous catheter. On 16 June 2015 she became unresponsive when a staff nurse left a port on the CVC (octopus) open to air as she turned away briefly during the process of flushing and changing this to a single needle connection. Mrs Steer was, up until that point, clinically well and lucid, and had been placed to sit in a chair after the morning ward round. The staff nurse attended and found her sitting in a chair when she commenced the procedure. The staff nurse knew that she should clamp the line but did not know the reasons for this. Neither did she know that undertaking this change whilst Mrs Steer was sitting up would present a risk of air embolization.

(1) Neither the staff nurse who changed the catheter nor the supervising senior staff nurse who was present throughout the procedure were aware of the risk of air embolization in the process of changing the catheter, where as it was in this case, left uncapped and unclamped. Whilst the attending Consultant was aware of the risk, the Serious Incident Investigator identified that it had not been possible to locate any literature or guidance on this point, having contacted other Trusts, and making an extensive literature search. The relevant bibliography was made available to the inquest.