Prevention of Future Deaths Report: Aarav Chopra (13 January 2025)

Summary

Aarav died from the consequences of a cardiac arrest caused by severe bleeding following damage to an intercostal artery during a liver biopsy which went undiagnosed and untreated at the

time of the procedure. His death was contributed to by poor planning before the procedure when there was no consideration of stopping antiplatelet medication, poor written and oral communication about the complication that occurred during the procedure all of which hampered treatment after his collapse. His death was contributed to by neglect. 

Content

MATTERS OF CONCERN

1. Prophylactic antibiotics for severely immunocompromised patients: The inquest heard evidence that patients like Aarav who are immunocompromised require additional prophylactic antibiotics for procedures. This is not covered in the current NICE guidelines. The concern is that there is currently no guidance for the use of prophylactic antibiotics in severely immunocompromised patients. 
2. Experience and competence of trainees: The inquest heard evidence that there was confusion around the experience and level of the trainee involved. He was thought to be an ST6 when he was an ST4. The concern is that there is no mechanism to evidence trainees experience and competence when they travel to various different hospital trusts as part of their training. 
3. Consent forms: The parents of Aarav were unaware that a trainee would be doing the liver biopsy. The concern is that there is currently no way to obtain consent when a trainee will be doing the procedure. 
4. Individual patient risk factors: Aarav had a complex medical background and several risk factors for any procedure. The concern is that there is currently no mechanism to identify individual patient’s risk factors so that all clinicians involved in their care are aware.  
5. Learning from deaths: The initial M&M meeting after Aarav’s death was described as inadequate. The concern is that there was no immediate learning from this tragedy and further consideration is needed to ensure a safe and effective mechanism to properly learn from deaths at the earliest opportunity. 
6. Electronic patient records: Evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. The concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment.