Mr Kevin George Mann · Prevention of Future Deaths report

On the 14th September 2016 an investigation commenced into the death of Mr Kevin George Mann. The conclusion of the Inquest was a narrative conclusion:

Mr Mann underwent a necessary surgical procedure - Ivor Lewis surgery- on 23rd May 2016. He had a poor post-operative recovery, which required prolonged ventilation. On 27th May 2016 he developed a pneumothorax. On the 27th May 2016 he also underwent a Visipaque contrast study. He should not have undergone the Visipaque procedure at that time, due to the pneumothorax. During the course of the Visipaque procedure, contrast entered the left main bronchus. Both the post-operative complication of pneumothorax and the entry of contrast material into the left main bronchus led to a deterioration in his respiratory state, from which he did not recover.

Mr Mann underwent an Ivor Lewis procedure for oesophageal cancer on the 23rd May 2016. On the 27th May 2016 reduced entry into the left side of his chest was noted and an x-ray confirmed a large left sided pneumothorax. The surgical team requested a further chest x-ray at 2:30 pm. The consultant surgeon confirmed that this should have been carried out prior to the Visipaque procedure. The chest x-ray was not carried out and the Visipaque procedure took place at around 16:10 on the 27th May 2016. The independent radiology expert confirmed that from the very first image available to the radiologist, the left pneumothorax was apparent. The radiologist should not have commenced the swallow procedure. The procedure was commenced and contrast material was seen to enter the left main bronchus. Despite this, the procedure continued and further contrast material is seen entering the left lung. Following the procedure there was a clinical deterioration in Mr Mann’s respiratory condition.

On the 28th May 2016 Mr Mann suffered a further deterioration in his clinical condition and required re-intubation and ventilation. From this time there was no significant or sustained recovery. He passed away in Queens Hospital on the 7th September 2016. The cause of death was found to be 1a: Acute Respiratory Distress Syndrome 1b: chemical pneumonitis and pneumothorax and 1c: Oesophageal Carcinoma (Ivor Lewis procedure).

1. An independent radiology expert confirmed that the left pneumothorax was clearly apparent from the imaging, prior to the swallow commencing. The independent expert, consultant surgeon and consultant intensivist all agreed that the procedure should not have been carried out, in light of the pneumothorax.

2. The radiologist who performed the procedure did not check the radiology system prior to commencing the swallow procedure. Had she checked the system she would have seen the x-ray taken at 12:37 showing the large left pneumothorax. She would also have seen the outstanding request for a chest x-ray. Both the independent radiology expert and the Trust radiology witness (Dr G), confirmed that recent radiology should be checked by the radiologist prior to performing this procedure.

3. The radiologist continued with the procedure after becoming aware of the passage of contrast material into the left main bronchus. The consultant surgeon and independent radiologist confirmed that the procedure should have been abandoned at that stage.

4. There was no documentation available within the records of the amount of contrast handed to Mr Mann or the amount of contrast ingested by him.

5. The policy in place regarding the Visipaque procedure does not require documentation of the amount of contrast material used, or for preliminary checks to be undertaken. The incident occurred over a year ago. Despite clear concerns being raised by the Consultant surgeon on 27 May 2016, there had been no adequate review of the Visipaque procedure policy, by the date of the Inquest hearing.