Mike Fell

5 Mar 2018 · Coroner Sarah Bourke · London Inner (North)

The coroner's concerns

1. unused taps left open to air
“it is not recorded in Mr [name redacted] notes that the taps had been checked and were closed”
2. lack of clamp on unused trauma lines
“The trauma lines used at the Royal London Hospital did not come with a clamp which enabled a line that was not in use to be closed”

Responses

2018-0100-Response-by-Barts-NHS-Trust.pdf ↗· Barts Health NHS Trust

2018-0100-Response-by-Royal-College-of-Anaesthetists.pdf ↗· Royal College of Anaesthetists

Stated action

“We will ensure these issues are brought to the attention of all trainees in anaesthesia and all Fellows and Members of the RCoA and AAGBI by publishing information in the Patient Safety Update, which is published quarterly by the RCoA on behalf of the Safe Anaesthesia Liaison Group (SALG - https://www.rcoa.ac.uk/salg), and is distributed to practising anaesthetists throughout the UK.”