On the 4t March, 2015 | commenced an investigation into the death Of Mrs. Gail Prentice_ The investigation concluded at the end of the inquest on the 17th April, 2015. The conclusion of the inquest was 'Complications of a surgical procedure on a background of multiple and severe health conditions

Mrs. Prentice, 46 years, had suffered multiple and serious ill health events in life including dialysis dependent diabetes, breast cancer with bilateral mastectomy, thyroidectomy; toe amputations, cardiac arrest and renal failure: She had been admitted to the Royal Glamorgan Hospital a fall and had suffered a PEA arrest . She had been ventilated fully and a previous attempt t0 extubate had failed. It was considered that a tracheostomy would assist Mrs. Prentice weaned off the ventilator but it was not an essential, life sustaining procedure Thepercutaneous dilation tracheostomy was performed in the LTU and commenced by ENT registrar under the supervision of= associate specialist ENT surgeon_ had previously performed only two percutaneous tracheostomies. Complications arose when the patient bled profusely after the insertion of the second dilator by The bleed could not be stemmed and Mrs. Prentice died in consequence. The post-mortem cause of death was given as 1a massive blood loss; and 1b transection of the brachiocephalic artery during attempted tracheostomy formation: Witness evidence confirmed that in patients requiring tracheostomy and where there had been previous neck surgery, ultrasound should have been undertaken to identify intemal structures within the altered neck anatomy and t0 determine the site of entry: At the ver least_the_tracheal rings_should_have_been counted in order_to avoid puncturing _the Cwm falling being artery on insertion_ The usual placement is between the 2"1 3" tracheal whereas in Mrs. Prentice; the site was low down the neck at the level of the 9" and rings: The outcome of the Cwm Taf University Health Board's investigation was submitted to the Coroner prior to the inquest In this report; the 'Ilessons learned' cited that patients previous medical history should be noted prior t0 tracheostomy; in the event of' previous neck surgery having been undertaken, a full ultrasound should be completed; and where previous neck surgery had been performed any new tracheostomy should be inserted in theatre and not in the ITU. The Health Board acknowledged its Guidelines for Tracheostomies did not address the scenaro of altered neck anatomy previous neck surgeryand this was an omission which it was seeking t0 address from these 'lessons leamed'

In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action in the area of: Ensuring the Hospital's Tracheostomy Guidelines take into account the checks required when there has been previous neck surgery; Percutaneous tracheostomies should be performed in the theatre environment rather than in the ITU; and Feedback to Health Boards that ENT surgeons have read its Guidelines