William Nichols · Prevention of Future Deaths report

On 07/01/20 an investigation was commenced into the death of William Nichols age 66 years. The investigation concluded at the end of the inquest on 20/04/23.

The conclusion of the inquest was:
Mr Nichols suffered a catastrophic haemorrhage from the site of a right femoral endarterectomy due to deep patch infection. The significance of blood in the wound discharge at 5 weeks post-surgery having not been acted upon, the opportunity to prevent a fatal outcome was lost.

The medical cause of death was:
1a) Hypovolaemic shock,
1b) Dehiscence of right femoral endarterectomy,
1c) Post-operative deep patch infection,
2) Type 2 diabetes mellitus, rheumatoid arthritis (on Tocilizumab), hypertension, ischaemic heart disease and atherosclerosis.

Mr Nichols underwent surgery, a femoral endarterectomy, on 20/11/19, and developed a lymphatic leak and a post-operative infection, from which he was at an increased risk of developing.

A week prior to his death, Mr Nichols suffered a herald bleed due to deep patch infection, and on the evening of 02/01/21 Mr Nichols suffered a fatal catastrophic haemorrhage from the site of the right femoral artery.

The blood in Mr Nichol’s wound discharge observed on 26/12/19 is likely to have been a herald bleed, and from then Mr Nichols was at a significant risk of catastrophic haemorrhage. On 26/12/19 Mr Nichols should have been instructed to attend hospital immediately where the management would have included an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.

On 27/12/19 Mr Nichols should have been admitted to hospital. At that point management would have been an urgent CT scan or CT angiogram before urgent surgery to eliminate the deep patch infection.

If surgery had been undertaken on 26/12/19 or 27/12/19, or at any time prior to the catastrophic bleed on 02/01/20, the deep patch infection would have been eliminated and it is likely that Mr Nichols would have survived

Despite the known catastrophic risks of deep patch infection following endarterectomy and the significance of a herald bleed:

(1) Inconsistency in understanding between the hospital and the community teams as to the procedure to follow post discharge from vascular surgery and the points of access in the event of concern or complication (including suspected infection, or bleeding).

(2) The absence of provision of documented advice to patients on discharge as to points of access in the event of concern or complication (including suspected infection or bleeding).

(3) Poor communication from the vascular ward when concerns were raised post-operatively, particularly the concern about bleeding in the wound discharge.

(4) Poor record keeping from the community team which meant that key clinical assessment information was not consistently recorded.