Recurance · prevention of future deaths reports
Pre-inquest brief
Unavailability of isoprenaline for heart transplant resuscitation
The earlier warning
Paul Ashton · 14 Apr 2014 · Alan Walsh, Manchester (West)
“Isoprenaline is not available in the United Kingdom and the source of the supply and the importance of the use of Isoprenaline in the resuscitation of heart transplanted patients should be brought to the attention of all hospitals and health professionals in the United Kingdom.”
What was promised
Stated action 1 · response to Paul Ashton (14 Apr 2014) · stated timescale: 14 May
“the Trust is now developing such guidelines (available 14" May)”
judiciary.uk/…/2014-0170-Response-by-Department-of-Health.pdf
Stated action 2 · response to Paul Ashton (14 Apr 2014) · stated timescale: immediately
“England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
judiciary.uk/…/2014-0170-Response-by-Department-of-Health.pdf
Stated action 3 · response to Paul Ashton (14 Apr 2014) · stated timescale: immediately
“NHS England will also ensure, immediately, through Area Medical Directors, that all hospitals are made aware of the ISHLT guidelines for heart transplant patients”
judiciary.uk/…/2014-0170-Response-by-Department-of-Health.pdf
What recurred
- 13 Oct 2014 · Mary Fenton · John Pollard · Closely related · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Paul Ashton · 14 Apr 2014
“Isoprenaline is not available in the United Kingdom and the source of the supply and the importance of the use of Isoprenaline in the resuscitation of heart transplanted patients should be brought to the attention of all hospitals and health professionals in the United Kingdom.”
Later · Mary Fenton · 13 Oct 2014
“This patient was being kept alive by the use of Isoprenaline. It transpires that there were severe shortages of this drug in the hospital but also nationally.”
What happened next
No web check of the stated actions has been published for this chain.