“Consultant Anaesthetist has advised that in response to this incident, the Derby…”

The coroner’s concerns

– Consultant Anaesthetist has advised that in response to this incident, the Derby Hospitals NHS Trust undertook the following action; · All 12 lead ECG devices were programmed to print a “Long QTc” warning when detected · An educational programme on LQTS was delivered to all Anaesthetists working in the Trust · A protocol was developed to require a pre-operative ECG for all patients taking drugs listed on the expert database at “high” and “intermediate” risk levels of causing cardiac arrest – this overrides the advice in the NICE CG3 document · When a prolonged QTc is discovered; o The patient is questioned about cardiac arrest or sudden unexpected death in a young family member; if this is discovered, the patient is referred to a cardiologist to exclude Congenital LQTS o The patient has plasma electrolyte levels (specifically potassium, magnesium and calcium) measured irrespective of any contrary advice in the NICE CG3 guideline. Any abnormal low level is treated before surgery · The Anaesthetist for the relevant operating list is alerted to any abnormal QTc finding · A protocol was developed to; (1) guide the safe administration of general anaesthesia to patients with LQTS, and (2) guide the optimum management of cardiac arrest if this occurs under anaesthesia · Investment was provided for electronic pumps to allow the ready availability of TIVA further advised that the likelihood of this event being due to a drug-related phenomenon was reported to the Medicines and Healthcare Products Regulatory Agency (MHRA) using the “yellow card” scheme. There were further communications with the MHRA suggesting that; · The product information for inhalational anaesthetic agents should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS · The product information for other drugs such as 5HT3 anti-emetics should contain a warning on the potential risks of cardiac arrest when administered to patients with LQTS during inhalational anaesthesia · The particular issues with antidepressant agents and LQTS should be highlighted in the regular bulletins from the Agency Furthermore, reported that recommendations be sent to NICE updating guideline CG3 to; · Instruct anaesthetists to consider drug-induced LQTS in their pre-operative assessment before following the recommendation not to perform a 12 lead ECG · Instruct anaesthetists to specifically examine the QTc interval in all preoperative ECGs performed for any indication · To require a 12 lead ECG to be recorded and the QTC to be specifically examined in all patients receiving agents deemed to be of “high” and “intermediate” risk of inducing cardiac arrest in LQTS advised that despite the above notifications recommendations, no action has been taken by these agencies. 6 and

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2014-0491

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0