Joyce Tozer
PFD Report
Historic (No Identified Response)
Coroner's Concerns (AI summary)
Omnipaque is frequently administered at doses exceeding manufacturer's guidelines, sometimes via central lines, which exposes interventional radiology patients to potential toxicity risks.
View full coroner's concerns
Consultant anaesthetist for the procedure on the 12th June 2015,gave evidence that since Mrs. Tozer'$ death, he has become concerned that the dose of 10Oml omnipaque record in the notes as being administered by the radiologist minutes before Tozer'$ sudden deterioration was well in excess of the dose recommended by the manufacturer of omnipaque (1ml/kg) especially as it was administered through & central line rather than peripheral venous access At this time Mrs Tozer' $ weight was 52kg) stated that he was concerned that the administration of a hypertonic solution at this dose into a central line may have affected Mrs. Tozer's heart rhythm although there was no way he could give an opinion as to whether it was the likely cause of her deterioration and death as the presentation of toxicity cannot be distinguished from an anaphylactoid reaction Igave evidence that having made enquiries about the dose with Lead Interventional Radiologist at the Trust, he has been told that a 10Oml dose is often used. am concerned that doses of omnipaque well in excess the and has during May line Mrs. being of the manufacturer' s guidelines are frequently administered, sometimes through central lines, and this practice could be exposing interventional radiology patients to risks from toxicity:
Sent To
- University Hospitals Birmingham NHS Foundation Trust
Response Status
Linked responses
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56-Day Deadline
10 Feb 2016
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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 26th June 2015 commenced an investigation into the death of Joyce Beatrice TOZER: The investigation concluded at the end of the inquest &th December 2015_ The conclusion of the inquest was that the deceased passed away at the Queen Elizabeth Hospital Birmingham on the 12th June 2015 as a result of a reaction to contrast material injected during an interventional radiology procedure to insert bilateral nephrostomies. not been possible to determine whether the reaction was due to an allergic response or a response to the toxicity of the 1OOml dose of omnipaque contrast solution given The need for bilateral nephrostomies was to manage urinary leak from a conduit anastomosis placed radical surgery on the 27th 2015 to treat recurrent anal cancer; The medical cause of death was: 1(a) Reaction to the administration of ominpaque contrast solution 2 Recent Surgeries for the treatment and management of anal cancer.
Circumstances of the Death
As a consequence of urostomy leakage following surgery on the 27th May 2015 Mrs. Tozer required bilateral nephrostomies. During the interventional radiology procedure to place the nephrostomies on the 12th June 2015 Mrs. Tozer remained stable until minutes after the injection through her central ofa 10Oml dose of omnipaque at which time her condition deteriorated dramatically leading to cardiac arrest from which she could not be resuscitated.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.