Prevention of future deaths report: Alexandra Briess (6 April 2023)

Summary

On 22 May 2021, 17-year-old Alexandra Briess underwent a tonsillectomy and subsequently experienced post-operative bleeding, requiring second operation carried out at Royal Berkshire Hospital on the 30 May. During anaesthesia, she experienced a sudden deterioration and cardiac arrest. Despite extensive resuscitation efforts, Alexandra died on the 31 May. Subsequent investigations have revealed that the most likely cause of her sudden deterioration was an anaphylactic reaction to Rocuronium.

In this report, the Coroner highlights connections between this case and three other Prevention of Future Deaths Report’s and suggests there needs to be greater funding and a role within the NHS to coordinate a national approach to prevent/reduce future deaths.

Content

The report highlights three other cases where similar concerns have been raised:

•  Shante Turay-Thomas
• Ruben Bousquet
• Celia Marsh

The Coroner states that it seems clear in all these cases, that the only way to improve understanding and prevent or reduce future deaths is to gather information nationally and fund appropriate research.

Coroner’s Matters of Concern

• There is significant goodwill and desire to improve amongst numerous organisations involved in anaphylaxis work. What is lacking is national leadership and funding. In my view, consideration should be given to creating a leadership role and responsibility within NHS England to coordinate a national approach.
• As considered by other coroners before me, it should be mandatory to refer fatal anaphylaxis cases. UK Fatal Anaphylaxis Registry (UKFAR) has indicated that they would be prepared to take on the role of receiving these reports (to avoid duplication for reporting clinicians), with the responsibility to forward the relevant information to other organisations such as the Medicines and Healthcare products Regulatory Agency (MHRA), where appropriate. Whilst my focus is on fatal anaphylaxis, inclusion of non-fatal cases would be a matter for the lead role to consider.
• Gathering data and using this to research and reduce the risk of future deaths requires funding, and this should be reviewed.
• Information sharing amongst the organisations referred to in this report should be straightforward. Confidentiality constraints are important, but not the same in the case of a deceased person as they are for a living person. I believe that a confidential advisory group has already started to consider this matter.
• Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients – so that there is a clear requirement for referral to UKFAR in the event of an unsuccessful resuscitation. This is currently being considered by the Resuscitation Council UK.