Prevention of Future Deaths report – Ann Geraghty

Summary

Ann Geraghty was being treated for heart failure at Good Hope Hospital and subsequently died following a cardiac arrest. In their report, the Coroner raised patient safety concerns relating to two periods of ventricular standstill (this is a rare issue when the heart stops beating and stands perfectly still), which were missed due to a combination of policy, staffing, workplace and equipment issues.

Content

While under continual cardiac monitoring from the 6– 8 March 2021, Ann Geraghty experienced two periods of ventricular standstill which were recorded but missed. Had these been detected she would have been admitted into a Critical Care Unit, though the Coroner noted that her subsequent cardiac arrest could not have been prevented.

The Coroner raises concerns that:

• The Philips central monitoring station used by the hospital detected the two periods of ventricular standstill but its alarm notification self-terminated when the heart rhythm had corrected.
• Following the Trust’s investigation, they had a discussion with the manufacturers of the equipment to establish whether the alarms can be configured in such a way that the alarm does not self-terminate when certain abnormal heart rhythms correct themselves but it does not appear a software update or alterative system has been developed to remedy this issue.
• Given Phillips is one of the largest providers of cardiac monitoring equipment to the NHS, the Coroner highlighted that there is a risk of future deaths occurring relating to the use of this type of Philips monitoring station without further changes.

This report was sent to Philips Electronics UK Ltd, University Hospitals Birmingham NHS Foundation Trust, NHS England and the family of the patient in this case.