Mrs. Gail Prentice · Prevention of Future Deaths report

On the 4th March, 2015 I commenced an investigation into the death of Mrs. Gail Prentice. The investigation concluded at the end of the inquest on the 17th April, 2015. The conclusion of the inquest was ‘Complications of a surgical procedure on a background of multiple and severe health conditions’.

Mrs. Prentice, 46 years, had suffered multiple and serious ill health events in life including dialysis dependent diabetes, breast cancer with bilateral mastectomy, thyroidectomy, toe amputations, cardiac arrest and renal failure. She had been admitted to the Royal Glamorgan Hospital falling a fall and had suffered a PEA arrest. She had been ventilated fully and a previous attempt to extubate had failed. It was considered that a tracheostomy would assist Mrs. Prentice being weaned off the ventilator but it was not an essential, life sustaining procedure.

The percutaneous dilation tracheostomy was performed in the ITU and commenced by ████████ ENT registrar under the supervision of ████████ associate specialist ENT surgeon. ████████ had previously performed only two percutaneous tracheostomies. Complications arose when the patient bled profusely after the insertion of the second dilator by ████████ The bleed could not be stemmed and Mrs. Prentice died in consequence.

The post-mortem cause of death was given as - 1a massive blood loss; and 1b transection of the brachiocephalic artery during attempted tracheostomy formation.

Witness evidence confirmed that in patients requiring tracheostomy and where there had been previous neck surgery, ultrasound should have been undertaken to identify internal structures within the altered neck anatomy and to determine the site of entry. At the very least, the tracheal rings should have been counted in order to avoid puncturing the artery on insertion. The usual placement is between the 2nd and 3rd tracheal rings whereas in Mrs. Prentice, the site was low down the neck at the level of the 9th and 13th rings.

The outcome of the Cwm Taf University Health Board’s investigation was submitted to the Coroner prior to the inquest. In this report, the ‘lessons learned’ cited that

• a patient’s previous medical history should be noted prior to tracheostomy;
• in the event of previous neck surgery having been undertaken, a full ultrasound should be completed; and
• where previous neck surgery had been performed any new tracheostomy should be inserted in theatre and not in the ITU.

The Health Board acknowledged that Guidelines for Tracheostomies did not address the scenario of altered neck anatomy post previous neck surgery and this was an omission which it was seeking to address from these ‘lessons learned’.

(1) The requirement for surgeons to acknowledge having read the Health Board’s Hospital Guidelines and those of other bodies e.g. NICE Guidelines