On 30 April 2019 commenced an investigation into the death of Brian Rochell born on 27 April 1944 investigation concluded at the end of the inquest on June 2021. The conclusion of the inquest was:- Brian was admitted to hospital on 10 April 2019 for a surgical procedure related to a cancer of the tongue This followed a previous cancer cured through radiotherapy. This is relevant because it had altered Brian's oral and throat physiology: surgery noted difficult airway and a concerning vessel preventing tracheostomy: surgery was successful, and Brian was sent to Critical Care for recovery. He acquired an infection which was successfully treated, and & decision was made to extubate him on 21 April 2019. This decision was made without adequate risk assessment and was inappropriate in the circumstances: Brian deteriorated in the hour following his extubation and clinicians were unable to intubate or oxygenate Brian resulting in a hypoxic brain injury. He died as a result f this on 26 April 2019 at the Royal Hallamshire Hospital

On 10 April 2019, Brian was admitted to hospital for a surgical procedure following diagnosis of cancer of the tongue He was ineligible for a radiological treatment approach because of previous cancer and therefore required a surgical approach. This surgery was also reconstructive in nature in an effort to enhance his quality of life. As the surgery commenced it was clear that the procedure was going to be complicated by an unusual throat anatomy including a vessel across the trachea that meant a tracheostomy would not be possible He was operated on using a nasal intubation tube and was sent to intensive care to recover with this in place. In mid-April; Brian developed a ventilator associated pneumonia which required the changing of the nasal tube to an oral one; This was a complex procedure undertaken by a senior member of staff: He documented in the record how the procedure was undertaken which was ultimately successful; but it was not something which was straightforward,and the relevant consultant described himself as anxious undertaking the procedure_ He had undertaken some discussions with relevant surgeons prior to the change and had a colleague on standby should be required during the procedure: Ultimately the procedure was a success, and he was recovering from this procedure and the infection: He was seen on several occasions and described as weak and remained unwell He did appear to make a significant improvement on 20 or 21 April 2019. and The The The the they

However; this was Easter weekend and therefore was a bank holiday on the Friday, Sunday and Monday: This is relevant because it meant that staffing levels were lower than during the week On 21 April 2019 a decision was made to try to extubate Brian because he appeared well. This was against a plan which was that no attempt was to be made to extubate Brian before the 23 April 2019. extubation was unsuccessful and resulted in Brian suffering hypoxic brain injury and ultimately dying on 26 April 2019. made the following findings at the conclusion of the evidence - The decision not to provide Brian with a tracheostomy at the start of the surgery was appropriate on the balance of probabilities The Way in which Brian's VAP infection was managed, including the changing of the tube on 15 April 2019 was appropriate on the balance of probabilities Following this there was a plan to consider extubating Brian after the Easter weekend (23 April 2019) and that included, where needed, consideration of a surgical tracheostomy. The decision to extubate Brian on 21 April 2019 was done without adequate risk assessment and with inappropriate weight placed on factors supporting a decision to extubate Brian on that Insufficient weight was placed on concerns raised by clinicians caring for Brian about the plan to extubate him on 21 April 2019. Attempts made to reintubate Brian on 21 April 2019 were done without a clear and adequate plan in place and staff were unclear what their role was in that Whilst ultimately, do not believe, on the balance of probabilities, that this would have altered the outcome, there is a possibility that this led to additional delay and Brian deprived of oxygen for longer than if there had been a clear articulated plan in place_

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action: would ask that your responses specifically consider the following The day: being being

What is the standard procedure for making referrals to professional bodies in cases causing concern?
2. Is that process affected by coroner's proceedings or other proceedings and if so how and why?