Complication of Procedure - May 2022

Learning Summary from Incident Reviews and Investigations

Summary

This incident involves a gentleman who was under the care respiratory services at the Royal Cornwall Hospitals Trust for pneumonia with empyema. Due to worsening symptoms the patient was re-referred to the pleural service by his GP on 13/12/2021 as an urgent referral and subsequently seen by the pleural service where a referral for a bronchoscopy was made to remove a mucus plug which had formed in the left main bronchus resulting in the consolidation of the left lung. During the elective outpatient bronchoscopy procedure on 13/01/2022 the patient became desaturated with oxygen levels dropping to 40% and went into respiratory arrest. Once stabilised, the patient was transferred to a medical ward for further care however, during the transfer the gentleman further deteriorated and became unresponsive. The patient passed away later that day as an inpatient on a medical ward

 Summary of findings, safety actions and recommendations

• The care delivered was in accordance with British Thoracic Society Guideline for Diagnostic Flexible Bronchoscopy in Adults which are NICE accredited.
• The patient was appropriately moved to the recovery area of the endoscopy suite for full medical review and further monitoring. The physiological monitoring stopped 51 minutes prior to transfer when the patient was moved to a private room with their family.
• The arrangements for the intra-hospital transfer of the patient were in keeping with Trust policy. There was approximately an hour between the transfer plan and movement of the patient. The multidisciplinary team did not review or consider how the potential further movement of the mucus plug during the transfer which could destabilise the patient warranting a high-risk transfer.

 Recommendations

• Patients with an urgent referral to respiratory services are given an indication of timeframe alongside contact details should they have concerns regarding changes in their condition.
• For therapeutic bronchoscopy procedures, the risk of the mucus plug breaking should be discussed in the patient briefing to ensure planning.
• Staff involved in traumatic events must be offered a debrief, optimally this is at the time of incident.
• Planning and risk management for intra-hospital transfers must include a recent set of physiological observations and additional key factors which could destabilise the patient to warrant a high-risk transfer.

Article ID: 289
Created: January 17, 2023
Last Updated: April 25, 2024

Online URL: https://elearning.cornwall.nhs.uk/site/kb/article.php?id=289