Teegan Barnard
17 Jan 2023 · Coroner Karen Henderson · West Sussex
The coroner's concerns
1. sudden inability to ventilate
“the 4 H's and 4 T's should be considered and excluded in any PEA cardiac arrest situation”
2. delayed recognition of surgical emphysema
“delay in the recognition of surgical emphysema by clinical attendees at the cardiac arrest”
3. lack of investigation into anaesthetic causes
“no steps were taken by the anaesthetic department at St Richard's Hospital, Chichester, either before or after the publication”
4. lack of proper system to trigger investigation
“senior management team within the Trust have not acknowledged that there was a lack of a proper and robust system in place to trigger an investigation”
Responses
2023-0014-Response-from-Care-Quality-Commission.pdf ↗· Care Quality Commission
Stated action
“We have also reviewed the following documents: 1.) Summing up and conclusion from HM Coroner 2.) Reg 28 Coroner evidence BARNARD - 6. Full Inquest Additional 1 3.) Reg 28 Evidence from Coroner BARNARD - 3. Full Inquest Exhibits Medical Records. 4.) Regulation 28 report. 5.) Reg 28 Evidence form Coroner BARNARD - 1. Full Inquest Statements”
2023-0014-Response-from-Health-Education-England.pdf ↗· Health Education England
2023-0014-Response-from-NHS-England.pdf ↗· NHS England
Stated action
“the Resuscitation Council reviewed the existing ALS guidance and materials, to include consultation of relevant experts. It was concluded that the ALS course did adequately cover the algorithm as well as cardiac arrest in pregnancy.”
2023-0014-Response-from-Royal-College-of-Anaesthetists-1.pdf ↗· University Hospitals Sussex NHS Foundation Trust
Stated action
“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”
2023-0014-Response-from-Royal-College-of-Anaesthetists.pdf ↗· Health Education England
Stated action
“We will amend our guidance accordingly, promote these changes to the specialty and embed this change into practice through the RCoA's Anaesthesia Clinical Services Accreditation scheme.”
2023-0014-Response-from-St-Richards-Hospital.pdf ↗· St Richard's Hospital