Mike Fell · Prevention of Future Deaths report

On 6 November 2017, Coroner Hassell commenced an investigation into the death of Mike Fell who was born on 24 July 1952. The investigation concluded at the end of the inquest, which was conducted by me on 5 March 2018.

The conclusion of the inquest was a narrative conclusion. I recorded a medical cause of death of:
1a Intracerebral haemorrhage
1b Cerebral air embolism
1c Elective abdominal aortic aneurysm repair performed on 26 October 2017

Mr Fell had an elective abdominal aortic aneurysm repair by way of an open surgical procedure at the Royal London Hospital on 26 October 2017. He was slightly acidotic following surgery. He was transferred to the Adult Critical Care Unit whilst sedated and ventilated with a trauma line in place. The trauma line had a 3-way tap connected. Within an hour of arriving in the ACCU, the IV fluid line was removed from the trauma line and the connector was capped with a white bung. It was noted that there was no clamp on the trauma line. Mr Fell went into cardiac arrest about 3 hours after surgery. Immediately prior to cardiac arrest, there was a rapid fall in his end-tidal carbon dioxide levels. During CPR, it was noted that the 3-way tap on the trauma line was “open to air” and it was sealed. It is unclear how or when the tap became “open to air”. Mr Fell’s heart started beating after 20 minutes of resuscitation but he remained very unstable. It was noted that he had a fixed, dilated right pupil. An emergency CT scan showed a large intracerebral bleed and air in his brain, liver and kidneys. Neurosurgeons advised that Mr Fell’s brain injury was unsurvivable. Mr Fell died at the hospital in the early hours of 27 October 2017. The evidence before me was that the air embolism was most likely to be the result of the 3-way tap on the trauma line being “open to air”. The Royal London Hospital is in the process of revising its procedures regarding the use of trauma lines outside of operating theatres in light of the issues raised by Mr Fell’s death.

(1) Whilst it is a matter of routine care to check that unused taps are “closed to air”, it is not recorded in Mr Fell’s notes that the taps had been checked and were closed. It is unclear how or when the 3-way tap on the trauma line became “open to air”
(2) The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed