Newcastle coroner finds lack of 'basic' medical device led to coronary bypass patient's death

An operation taking place
-Credit: (Image: PA)

A coronary bypass patient's death was partly due to NHS supply problems, a Tyneside coroner has warned.

Michael Trevor Walton, 66, died on July 13 last year in a Carlisle hospice. A month earlier he had undergone surgery. At an inquest which concluded on July 3, senior coroner for Newcastle and North Tyneside Georgina Nolan found that the absence of a "basic and inexpensive" kind of cannula - preferred by the operating surgeon- contributed to Mr Walton's death.

At an inquest, Ms Nolan's formal conclusion was that Mr Walton's death had been "due to a very rare complication of a necessary surgical procedure".

The coroner has now written to both the Department of Health and Social Care and NHS England urging them to take action to prevent a similar situation re-occurring.

Mr Walton had been living with coronary artery disease and he underwent elective bypass surgery on June 13 2023. He had been identified as a "good candidate for surgery" the coroner said, and was at low risk of complications.

However, in the formal "prevention of future deaths" report produced by Ms Nolan, the coroner wrote that: "The Consultant Surgeon’s preferred choice of cannula was not available due to supply issues and a cannula with a slighter shorter tip was therefore used by the operating surgeon."

During the operation, the aortic cannula was dislodged and this led to a interrupted blood flow to Mr Walton's brain - and resulting in him suffering an hypoxic brain injury. He died due to this in a the Eden Valley Hospice a month later.

The coroner has now laid out how surgeons should not be "restricted" by supply shortages and that using "sub-optimal" medical equipment posed an avoidable risk of death for NHS patients.

In her full report, Ms Nolan added: "The surgeon’s preferred choice of cannula was not available for the procedure due to supply issues. A cannula with a shorter tip was therefore used for the procedure.

"The cannula type contributed to its dislodgement from the lumen of the aorta and to Mr Walton’s death An arterial catheter is a basic and inexpensive medical device used daily in a hospital setting.

"Operating surgeons are best placed to decide on the most appropriate equipment to use and should not be restricted in that choice by supply shortages. Using sub-optimal medical equipment poses an avoidable risk to patients of significant harm including death."

The authorities must respond to the report formally and give details of how they are to respond within 56 days. NHS England has shared its "deepest sympathies" for Mr Walton's family and friends and the organisation is to respond fully in due course.

A Department for Health and Social Care spokesperson said: “Our deepest sympathies are with Michael’s family and friends in this tragic case. It is important that we learn the lessons from every prevention of future deaths report.

“The department has received the report and will consider it carefully before responding in due course."