“There was an error of omission in record keeping and in handover from critical care to…”

The coroner’s concerns

– (1) There was an error of omission in record keeping and in handover from critical care to surgery, and that this error likely contributed to Ian’s death. (2) There was no entry in Ian’s hospital notes to indicate the full extent of the critical incident of 5 June 2022. (3) There was a lack of information on handover from critical care to the surgical team regarding the full extent of the critical incident of the 5 June 2022. There was a verbal handover which was brief and vague. There was no formal written handover process highlighting significant events. (4) The error of omission was unexplained and has not been investigated by the NHS. The evidence regarding the error of omission came to light after the completion of the NHS investigation into Ian’s death. The Consultant Anaesthetist involved in Ian’s operation discovered the fact of the critical incident of 5 June 2022 on a later examination of ventilator data. The data indicated that Ian deteriorated significantly, that he was close to a cardiac arrest and the critical care team saved his life. (5) The surgical and anaesthetic team had no reason to suspect a secondary brain injury. The team had no information on Ian’s neurological status. Ian is likely to have suffered a hypoxic brain injury during the critical incident of 5th June. This will have undermined his resilience and ability to physically withstand the rigors of spinal surgery and airway exchange. (6) Had the surgical and anaesthetic team known of the extent of the critical incident of 5 June, the operation would have been delayed and further tests and assessments undertaken. The anaesthetic team may have opted for elective tracheostomy if the full circumstances of the critical incident of 5 June 2022 had been known. An elective tracheostomy would have led to a different outcome because it would have avoided the complications that 3 Information Classification: PUBLIC ensued from the attempted airway exchange. (7) I note the NHS Investigator and the Investigatory Panel both recommended that action is required for the handover of complex patients. The panel recommended as follows: More robust and formalised handover of complex patients before transfer to theatre, to include review of airway management, cardiopulmonary status, potential avenues of deterioration and any significant events during admission (8) The Trust had chosen not to accept this recommendation but at the time the Trust made that decision it was not aware of the extent and significance of the error of omission.

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, 2023-0519

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