Regulation 28: Report to Prevent Future Deaths February 2017

from the Legal and Ethical Policy Unit (LEPU)

The Intensive Care Society wishes to draw its members attention to the recent Coroner’s report into the events surrounding the death of a patient. The patient was admitted to hospital having suffered a stroke, and went on to develop malignant middle cerebral artery syndrome. The doctors involved in their care referred them to the tertiary neurosurgical service for decompressive hemicraniectomy. They were accepted by the surgical team, but were not transferred due to a lack of ICU beds. The patient was referred to a second regional neurosurgical unit but the surgeons on this site insisted the original unit should accept the patient for surgery regardless of ICU bed state. The original unit did then accept the patient for surgery, but during this prolonged period of discussion between multiple teams and units the patient had deteriorated further and it became clear they would not survive with or without an operation. The patient subsequently died.

The coroner found there was a lack of written protocols in place to set out a clear pathway for referral for emergency neurosurgery, which led to a critical delay in the patient’s care. Her recommendations include organisations having in place a system to allow patients to be transferred immediately to their local neurosurgery unit. This may mean that a critical care bed would have to be found for that patient afterwards “even if that requires extensive ‘bed juggling’ by critical care doctors or in extreme cases, post-operative care being provided elsewhere”. This is in keeping with the 2015 Care Quality Statement by the Society of British Neurological Surgeons stating that ‘admission to a regional neurosurgical unit for life-saving emergency surgery should never be delayed” and “the lack of critical care beds must not be a reason for refusing admission for patients requiring urgent surgery”. The coroner proposes that this principle should cover all types of life-saving surgery and not solely neurosurgery.

The coroner’s recommendations could potentially have wide ranging implications for critical care units serving regional neurosciences centres and other tertiary surgical services. Individual trusts and health boards should ensure they have clear pathway for the transfer and care of patients requiring urgent neurosurgical procedures to proceed in a time-critical manner.


LEPU is a joint initiative by the FICM and the Intensive Care Society reporting to the Joint Standards Committee.