Mr C suffered a fall whilst playing badminton and was knocked unconscious on 4 July 2011. He sustained a head injury and was taken to hospital where he was found to have a fracture of the right temporal region and severe contusions throughout the brain. He was transferred to Queens Hospital for neurosurgical care and on 5 July 2011 he underwent a left frontal craniectomy.
On 15 July 2011 a decision was made for a percutaneous tracheostomy to be placed to assist Mr C breathing. During the procedure, Mr C suffered a percutaneous fracture of the trachea causing injury to the brachio-cephalic artery which caused a significant arterial bleed.
Following the bleed, which occurred before 15:45hrs on 15 July 2011, Mr C did not undergo a CT scan until approximately 12:00hrs on 16 July 2011 and it was not reported until 13:30hrs. He was not transferred to a specialist Cardiothoracic Centre, until approximately 16:00hrs. He was taken into theatre at approximately 17:30hrs when repair surgery took place.
A Consultant Cardiothoracic Surgeon, performed an open repair and was able to repair the artery the same day. Following the operation, Mr C was returned to Queens Hospital. The surgeon was critical of the delay in Mr C being transferred, particularly in light of the extent of damage which had been caused to the artery during the tracheostomy procedure, including the lack of blood flow through the brachiocephalic artery. Furthermore, the Coroner was concerned enough at the Inquest to have made a Regulation 28 recommendation in respect of the delay.
On 8 August 2011, Mr C was transferred from Queens Hospital Romford to Broomfield Hospital with a tracheostomy tube in situ. He was making progress with input from various specialists.
On 20 October a decision was made for a supra-pubic catheter to be inserted. This procedure, undertaken by two junior doctors, appeared to go well. However, later that day, Mr C suffered a cardiac arrest and started bleeding profusely from the mouth. Emergency treatment was provided, but Mr C was pronounced dead at 14.40 hours.
- A post mortem carried out on 26 October 2011 identified the cause of death as follows:
1(a) tracheo-brachiocephalic artery fistula
1(b) repair of iatrogenic brachiocephalic artery injury
1(c) tracheostomy following head injury
An Inquest was held in November 2013. We wrote to the Trust setting out our allegations of negligence following the Inquest, including:
- A failure to carry out the tracheostomy on 15 July 2011 with an appropriate degree of care.
- A failure to consider/exclude the possibility of injury to the brachiocephalic artery at the time of the torrential bleed.
- A failure to expedite a CT scan in light of the seriousness of Mr C's condition. Surgery could have taken place on 15 July 2011 instead of 16 July 2011.
- A failure to expedite transfer in light of the CT scan
As a result of the failures above:
- The delay in prompt, appropriate medical attention in response to the arterial bleed, causing further brain damage.
- Causing Mr C to have to undergo unnecessary surgery, both the brachiocephalic repair and open tracheostomy.
- Requiring a prolonged recovery and transfer to a different hospital where Mr C received substandard nursing care.
- Restricting what little function he had left for the last 3 months of his life.
Shortly after a Letter of Claim was sent, we were able to negotiate settlement on behalf of the family without an admission of liability.
After settlement was reached, Mr C's daughter emailed:
"I have been extremely pleased with your work and…………..I appreciate all the work you have done in respect of my late father".
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