UK Inquiry Tracker

Patricia Parker

PFD Report Historic (No Identified Response) Ref: 2017-0454

Date of Report 24 July 2017

Coroner Thomas Osborne

Coroner Area Milton Keynes

Response Deadline est. 18 September 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

Coroner's Concerns (AI summary)

Numerous sedation guidelines are not widely known by clinicians, highlighting a need for better training and awareness of sedation risks, especially in the elderly.

View full coroner's concerns

(1 )That the numerous guidelines relating to the use of sedation should be more widely brought to the attention of all clinicians undertaking sedation.

(2) That NHS England should highlight the problems arising from the use of sedation particular1y in the elder1y and encourage all Hospitals to develop training locally for their clinical staff. 7

Sent To

NHS England

Response Status

Linked responses 0 of 1

56-Day Deadline 18 Sep 2017

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Report Sections

Investigation and Inquest

On 10 th January 2017 I commenced an investigation into the death of Patricia Lilian Parker, aged 89 . The investigation concluded at the end of the inquest on 11th July 2017. The conclusion of the inquest was a Narrative conclusion: The deceased underwent an endoscopic procedure under sedation at Milton Keynes Hospital on 5th January 2017. She suffered a cardiac arrest following sedation and despite resuscitation she died at 04. 15 on the 8th January 2017. The medical cause of death was recorded as 1 (a) Hypoxic brain injury following cardiac arrest during diagnostic endoscopy 2) Gallstones, Atrial Fibrillation

Circumstances of the Death

th On 5 Jan 2017 the deceased was prepared for an endoscopy. Her throat was sprayed with Xylocane she was then given Midazalem ) and Pethidine and the procedure was started. Her saturations dropped suddenly and she became cyanosed, the procedure was immediately stopped but she went into cardiac arrest. CPR was started, she was intubated and admitted to Department of Critical Care for further management. Her family were informed of the situation and the possible cause of arrest was likely to be due to her sedation prior to endoscopy. She died on 8 th January 2017. There was a failure to adhere to the Trust's Intravenous Sedation Policy for adults and BNF (British National Formulary) recommendations in relation to titrating of the sedation.

Action Should Be Taken

YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by th September 2017. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons
• The Family of Mrs Parker
• Milton Keynes University Hospital I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish ei her or both in a complete or redacted or summary form. He may send a copy of this report t y erson who he believes may find it useful or of interest. You may make repre ntations 0'""'".,.n=coroner, at the time of your response, about the release or the publi tion of yo r o s by the Chief Coroner. Tom Osborne Senior Coroner for Milton Keynes

Copies Sent To

Milton Keynes University Hospital