Hospital’s failures cause the death of cancer patient

Monday 29 March 2010

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An inquest into the death of Myron Hall culminated on 21 March 2010 with HM Deputy Coroner for Bridgend, Mr. Huw Medlicott, returning a narrative verdict recording that Myron's death was caused by numerous individual and system failures in Royal Glamorgan Hospital in Wales. The narrative verdict:

"The deceased, Myron David Hall, having discovered a lump in his neck in June 2006 was referred by his general practitioner for assessment and any necessary treatment.He was initially seen at the Prince Charles Hospital in Merthyr Tydfil and investigations took place between October 2006 and January 2007 following which a diagnosis was somewhat belatedly made of a squamous carcinoma of the tongue which had metastasized into the lymph nodes. Surgery was recommended and accepted by the deceased and following the uneventful insertion of a peg to assist in feeding, he was taken to theatre at the Royal Glamorgan Hospital on 22nd January for excision of the carcinoma by way of a planned hemiglossectomy (removal of one half of the tongue) and taking out the metastases in the lymph nodes. Full investigations (including MRI and CT scanning) were not available to the surgeons prior to commencement of that operation; had they been so available the surgery would not have taken place.During the surgery on 22nd January a percutaneous tracheostomy tube insertion was prematurely undertaken before a proper examination of the site of the carcinoma was undertaken which immediately showed that the carcinoma had crossed the mid line of the tongue, hence necessitating far greater surgery than had been discussed with the patient or planned. Had that examination taken place prior to the commencement of any surgery, the tracheostomy would have been deemed unnecessary and would not have been undertaken.The tracheostomy appears to have been successfully undertaken. The deceased, having indicated that his preferred option thereafter was not surgery but to undertake radio and chemo therapy, was referred to the Velindre Cancer Centre. Prior to that transfer a decision was made firstly to leave the tracheostomy in place, and then to change the tracheostomy tube within four days of the original insertion to provide a fenestrated tube to allow better vocal communication.That change of tracheostomy tube was undertaken on 26th January and the procedure caused the deceased considerable pain. That procedure resulted in a size 10 tube being inserted where a size 8 tube had originally been inserted, and more importantly did not go through the original tracheostomy site and into the trachea but was forced down through tissue adjacent to the trachea resulting in the tip of the tube coming into very close proximity to an aberrant or anomalous artery very close to and arising from the innominate artery, thus causing an obvious risk of erosion and thus serious bleeding.Although checks were undertaken the misplacement of the tracheostomy was missed both upon the original insertion and when subsequent symptoms indicated that there may well be a problem.Upon his transfer to the Velindre Cancer Unit on 31st January 2007 the deceased was noted to have a misplaced tracheostomy tube by an experienced member of the nursing team (something that had not been previously noted at the Royal Glamorgan Hospital.) A serious bleed resulting in the loss of approximately 300 millilitres of blood took place at Velindre Hospital and the description of this as "spurting" or "gushing" suggested an arterial bleed resulting in the deceased being transferred back to the Royal Glamorgan Hospital. It appears that the seriousness of the nature of the bleed was once again not picked up although the issue of the false track was identified and remedied by the insertion of a fresh tracheostomy tube. Following the re-fashioning of the tracheostomy tube on 1st February no further thought appears to have been given to considering the nature of or identifying the source of the bleed (which was indeed arterial) and ultimately there was a massive haemorrhage in the early hours of 5th February 2007 caused by the damage to or erosion of the wall of an aberrant or anomalous artery caused by the tracheostomy tube in the false track. Blood loss on the 5th February was catastrophic and fatal leading to the deceased's untimely death.

Myrons parents were represented by Kirsten Heaven of garden court chambers and Joanne Kearsley and Gemma Vine of Farleys Solicitors.

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