On 29/07/2013 | commenced an investigation into the death of James LEWIS, then Years_ The investigation was concluded at the end of the inquest on 26/11/2013. The conclusion of the inquest was narrative that Mr Lewis died as a result of the complications that ensued following an anaphylactic reaction of unknown origin. Difficulty was encountered in medically securing his airway: He went into respiratory then cardiac arrest He died at 3.25 on the 24th July 2013_ The medical cause of death being: 1a) Consistent with anaphylaxis
2) Ischaemic Heart Disease due to Coronary Artery Atherosclerosis; Adhesive Pericarditis_

Mr Lewis had been suffering from various types of physical health problems, including related weight management issues (clinical obesity) In early hours of the 24th 2013 he called for his wife's help as he was feeling unwell He believed that he had had an allergic reaction and despite having taken oral steroids (prescribed to the deceased for another medical condition) his symptoms persisted He had some time previously had an allergic reaction which had settled uneventfully_ took her husband to hospital whereupon a diagnosis of anaphylaxis was made_ Appropriate emergency medical management was initiated however, the doctors were concerned about safe maintenance of Mr Lewis' airway (his tongue and face were swollen and he was having difficulty speaking). The medical team (initially consisting of ER Consultant and Anaesthesiologists) decided that it would be in the patient's best interests for his airway to be pro-actively medically managed. Preparatory steps were therefore taken_ Whilst poorly Mr Lewis' condition was deemed to be relatively stable at this It was the medical view that an Ear; Nose and Throat (ENT) doctor should be in attendance s0 that in the event that conventional intubation proved unsuccessful, surgical management could be initiated immediately_ The overall viewpoint was that it would be an ENT doctor who had the necessary skills and expertise to surgically manage the airway in such circumstances The 1st on call for ENT (a Senior House Officer SHO) was based at the hospital caring for Mr Lewis_ however it was held that such a junior Dr would notldid not have had sufficient clinical experienced to carry out surgical management The_hospital at which the deceased was being_cared for was the only_hospital within the Trust Barry aged the July point.

providing on calllemergency coverltheatre availability for ENT services The only theatre at this hospital actively providing services of hours was the ENT theatre_ As such, there was only one Operating Department Technician (ODT) providing night cover. The 2nd on call ENT Dr (a middlelstaff grade) was therefore called to attend Mr Lewis At the material time, the 2nd on call was covering 3 hospitals, all in separate towns but within the same acute Trust When contacted, he drove from one hospital to the other. Upon reaching the car park; the staff grade Dr received a call regarding a very ill patient at the hospital that he had just left: Advice was sought with regard to that patient's treatment and whether the Dr could return forthwith: The Dr established that the patient in question had been stabilised sufficiently and he therefore decided to make his way into the hospital in order to attend to Mr Lewis first. He headed up to theatre as he had been told that this was where intubation was to take place_ En route, he met the SHO. They subsequently made their way to Accident and Emergency. Just to their arrival, the deceased's condition had rapidly deteriorated. He went into respiratory and then cardiac arrest Cardio-pulmonary resuscitationladvanced life support (ALS) was carried out. The anaesthetic team struggled to secure the patient's airway by conventional intubation methods (3 different ways were attempted) This was due to the patient's weight problems (neck sizelstructure) and the swelling caused by the anaphylactic reaction. When ENT arrived, attempts were made to insert a surgical airway (tracheostomylcrycothyrotomy)_ However the ENT Dr experienced difficulties, over and above the patient's idiosyncrasies, in that: i) the standard pre-packed airway surgical sets available within the ER contained only smaller sized surgical instrumentation: Whilst there were routinely two packs of each of the four types of sets held, only contained one size of instrument, smaller in size_ In Mr Lewis' case, this meant that the skin retractor was too small and ineffective_ i) Similarly, the scalpel within the pack was a 'disposable'_ This presented difficulties in securing an incision of sufficient depthlsize_ iii) The ENT Dr felt that the content of the sets in the ER differed to those that he was used to_ iv) There was no additional, single, separately packed, larger instrumentation available in the ER (e.g: larger skin retractors/reusable metal handled scalpels to which the correct size of blade could be attached)_ v) Whilst reusable scalpels were available in main theatres the only person with ready access and practical knowledge of location and availability (out of hours) was the ODT. However he was proactively involved in the resuscitation process and therefore could not be dispatched: Clinical staff felt unable to gain access to theatres, that there was no night manager on sitelavailable to call upon and that the only other option open to them might have been to call switchboard to see if porter was available to assist regarding theatre access_ The ENT Dr did eventually manage to secure a surgical airway by 'feeling' for the relevant anatomical point once some form of incision had been achieved The patient was 'bagged' and ALS continued Following a downtime of 50 minutes the decision was taken to withdraw treatment and Mr Lewis died at 03.25.

In my opinion action should be taken to prevent future deaths and believe you (ANDIOR your organisation) have the power to take such action_