On 24/05/2015 the Deceased, aged 77, was admitted to Bedford Hospital with symptoms suggestive of infective exacerbation of Chronic Obstructive Pulmonary Disease (COPD) and heart failure. The Deceased had established coronary artery disease. He was admitted under the care of the cardiology team and was managed on the Coronary Care Unit.
On the 27/05/2015 he suffered a cardiac arrest from which he was successfully resuscitated. As part of his resuscitation, he was commenced on intravenous Amiodarone which required the insertion of a central venous catheter. A right internal jugular central venous catheter was inserted by an Intensive Treatment Unit anaesthetist using an aseptic technique under ultrasound guidance.
After undergoing coronary angiography on the 28/05/2015, it was decided to transfer him to Papworth Hospital for an implantable defibrillator to be fitted on 02/06/2015.
On 01/06/2015, as he was no longer receiving IV medication through his central line, it was deemed appropriate to have it removed. It is averred that the Deceased's COPD, significant cardiac failure, steroid therapy, poorly controlled diabetes, history of smoking and elevated Waterlow Risk Assessment score placed in him a high risk category of patients for such a procedure, mandating a high level of care and risk assessment in respect of the removal procedure.
Guidelines state that prior to line removal a patient should be risk assessed and they should be tested to see whether they can tolerate the Trendelenburg position and if they can perform the Valsalva manoeuvre.
At around 13:30 on 01/06/2015, nursing staff removed the central line and applied a dressing. No tests or risk assessments of the Deceased's ability to perform the Valsalva manoeuvre or to tolerate the Trendelenburg position were recorded as being carried out prior to the removal of the central line. It is alleged that no Tegaderm or a similar occlusive dressing was applied, but only a gauze dressing applied with tape.
There were conflicting accounts of how the CVC line was removed and it was alleged that immediately prior to undertaking the removal the Deceased was asked to take a breath in as the catheter was withdrawn. No contemporaneous clinical records were made of removal procedure or the necessary preparation, plan and risk assessments.
Following the line removal, the Deceased was left lying flat until approximately 14:15. At that point he wished to sit up out of bed and was assisted into a chair by nursing staff. Once upright, the Deceased started to complain of shortness of breath and of feeling very hot. The Claimant, who was sat with him sought the immediate assistance of the nursing staff. The Deceased was put back into bed and started on supplemental oxygen.
After putting the Deceased in bed, nursing staff left the Claimant with him at his bedside. The Claimant was told that he had fallen asleep. After a few minutes of sitting next to him the Claimant became concerned about the Deceased and called staff. The ward manager arrived and was unable to rouse the Deceased. A consultant was called, and found the Deceased unresponsive. He was taken immediately to scanning.
A CT scan of the head confirmed a large cerebral air embolism. The findings were discussed with the neurosurgical unit at Addenbrooke's Hospital, who advised that this was most likely an air embolism secondary to the removal of the central venous line. They advised that this was not amenable to neurosurgical intervention, and that the Deceased was extremely unlikely to recover.
The Deceased remained unresponsive until his death at 23:00 on 2nd June 2015.
The Deceased suffered a fatal cerebral air embolism secondary to CVC line removal.
An inquest was held in January 2016 and the verdict given by the Coroner was that a failure in the central venous line removal procedure caused an air embolism to the brain resulting in death.
Following the inquest the Defendant was invited to admit breach of duty and causation. They responded with a denial of liability. At the same time they made an offer to settle without any admissions in the sum of £10,000. This was rejected by the Claimant.
A Letter of Claim was sent to the Defendant on 13/07/2017. Allegations put forward related to the procedure for the removal of the central line being carried out negligently; failure to apply an occlusive or semi-occlusive dressing such as Tegaderm, and instead applying a dressing of gauze adhered with tape only; failure to adequately assess the risk of the removal procedure in the context of the Deceased's clinical condition and high risk presentation; failure to risk assess the Deceased's ability to tolerate the Valsalva manoeuvre or the Trendelenburg position.
It was the Claimant's case that nursing staff had failed to follow the guidelines for safe CVC line removal and failed to take adequate steps to ensure that the dressing used in the procedure was sufficiently air tight.
The Defendant sent a Letter of Response on 15/11/2017 denying liability. They stated that nursing staff had considered the Trendelenburg position and that the Deceased was unable to tolerate it but that it had not been recorded. Similarly in relation to the Valsalva manoeuvre they stated that staff had considered that the Deceased would not be able to perform this and so had asked him to take a breath in and hold it whilst the line was removed. Again this was not recorded. It was averred that these actions did not fall below a reasonable standard of care. Nursing staff stated that a Tegaderm dressing was used to cover the wound site on line removal.
The Defendant stated that they were unable to explain precisely how the Deceased had developed the air embolism but that it was a recognised rare event after central line removal. The Claimant was invited to withdraw her claim against the Trust.
Proceedings were issued against the Defendant on 06/06/2018 and served on 02/10/2018. The Defendant requested an extension of time for service of the Defence which was refused. Prior to service of the Defence the Defendant made an offer to settle the claim in the sum of £25,000 which was accepted by the Claimant.
The claim was settled on a global basis for £25,000. A rough breakdown of the settlement figure is as follows:
General damages: £1,500; Bereavement award £12,980
Special damages: £3,000 funeral expenses; £7,500 loss of services, love and affection
The defendant also agreed to pay the claimant's costs of the case, which had been run under a conditional fee agreement.