“To BHRT (A).This was a significant adverse event and the death was preventable”

The coroner’s concerns

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— To BHRT (A).This was a significant adverse event and the death was preventable. However, there has been no serious incident report (SIR) into the death. The importance of the SIR process is to consider root causes and importantly, to make recommendations and implement an action plan. Learning lessons is a key feature of the process. (B). The neuroradiological review of the CT scan in November 2015 and early December 2015 did not highlight the obvious brain parenchymal herniation through the pre-existing burr hole as well as other interval change and this was a missed opportunity of flagging a clear indicator of rising intracranial pressure. Furthermore, there is now a separate investigation on the death of another person (SP) where involvement of the neuroradiology department at the Queens hospital is a central issue. (C). The last face to face consultation between the Neurosurgeon and the deceased was on the 3rd February 2016 but the written neuroradiological report of the January 26th CT scan was not available until the 4th February 2016 and so this report was not considered by the Neurosurgeon as it was not available for this key consultation. This report did highlight some alarming features of herniation but this vital information was therefore not considered. (D). The consultant neurosurgeons examination on the 2"? December 2015 did not find frank papilledema and yet an examination by a consultant ophthalmologist at the Luton and Dunstable hospital on the 18"" November 2015 and 24"" December 2015 had found papilledema at both appointments. The consultant neurologist’s referral letter from Luton and Dunstable indicated a finding of papilledema also and stated an ophthalmic review was being sought but there appears to have been no attempt to find the outcome of the Luton assessments. Further, and in the alternative, no specialist ophthalmic advice was sought by the neurosurgeon even though there had been lengthy ophthalmic follow up over a number of years after the third ventriculostomy in 2007 and also given the recorded findings of the consultant neurologist in Luton. To BHRT and the CQC (E). There have been a number of Regulation 28 reports issued by Nadia Persaud, Senior Coroner for the area of the Eastern Area of Greater London raising concerns over a number of clinical deaths. In addition, a CQC inspection in September 2016 and October 2016 (report published March 2017) have made findings of the trust ‘requiring improvement’ in a number of respects when measuring against key standards. The CQC report published in December 2013 referred to a previous mortality alert concerning septicaemia shunting in hydrocephalus where the hospital review found no obvious deficits in clinical or operative quality. This inquest was an independent review where expert evidence exposed shortcomings in the management of hydrocephalus. It is not clear whether the circumstances of this death were disclosed during the most recent inspection Coroner's Office, Lawrence Court, Princes Street, Huntingdon, Cambridgeshire, PE29 3PA. Tel 0345 045 1364 | Fax 01480 372777 NHS ENGLAND (F). A point explored in the investigation was the administration of opioid analgesia in someone who has raised intracranial pressure. This was looking at an opiate acting as a respiratory depressant with a consequent rise in the level of carbon dioxide in the blood which in turn could further raise ICP provoked by hypercapnia. This could cause a fatality. Luton and Dunstable hospital have designed a standard operating procedure to address this and it raises a question of whether this should be distributed nationally so as to achieve consistency of approach.

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, 2017-0457

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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