Desiree Harmony Falvo · Prevention of Future Deaths report

On Saturday 24th August 2013 I commenced an investigation into the death of Ms Desiree Harmony Falvo, aged 35 years. The investigation concluded at the end of the inquest on 26th March 2014. The conclusion of the inquest was:

Medical Cause of Death

1 (a) Hypoxic Brain Injury

(b) Cardiorespiratory Arrest

(c) Upper airway tract obstruction (treated August 2013).

How, when and where and in what circumstances the deceased came by her death:

Ms Falvo had congenital laryngeal stridor due to immobile vocal cords which required multiple surgical procedures. On 20/8/2013 she had a relatively minor procedure to assess her suitability for reconstructive surgery at Charing Cross Hospital. This appeared to go well. Post operatively she did not feel right in herself, however was discharged objectively fit at approximately 13:30 on 22/8/2013.
That evening she developed difficulty in breathing over a couple of hours, vomited then deteriorated rapidly. LAS was called and she was transferred to St George's Hospital. On arrival she was in extremis.
The treating doctors had difficulty in securing her airway due to obstruction around the vocal cord area, scarring in her neck and her body habitus, during which she arrested.

By the time the ENT Registrar had arrived and completed a tracheostomy, she had suffered hypoxic brain injury. She died at 05:58 on ITU at St George's Hospital.

The cause deterioration is unknown.

Conclusion of the Coroner as to the death

Narrative- see above.

It was clear from the evidence taken during the inquest that an expert team was attempting to resuscitate Ms Falvo in very difficult circumstances. A paediatric intensivist had almost got the tracheostomy in place just as the ENT Registrar had arrived and took over the surgical tracheostomy insertion. However a recurrent theme of the evidence was that the procedure required to secure Ms Falvo’s airway was the expertise of the non resident ENT surgeon. I understand from discussion with the experts called to give evidence, that there are insufficient ENT Registrars to be resident in all A&E Departments and that whilst those working in A&E and expected to manage airways are trained in emergency surgical tracheostomy techniques, many of these clinicians feel uneasy and lack the confidence to perform such procedures.

(1) That A&E departments have insufficient cover to ensure that they have on site clinicians able to secure airways via emergency surgical tracheotomy,

(2) That the training planned and provided to those expected to manage and secure airways including the use as appropriate of surgical tracheotomy, is reviewed and upgraded such that those clinicians have both the skills and confidence to perform such procedures in an emergency situation.