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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. 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.

Since 2015 Quomodus has developed the digital course 'Diathermy – a practical guide to electrosurgery' for surgeons and other professional users of electrosurgery. The 30-minute course covers the history of electrosurgery, indication and proper use, adverse effects and complications associated with the use of diathermy. The course has been tested and quality assured by health professionals in Scandinavia. The course is flexible, user friendly and applies to all models of diathermy equipment currently on the market.

CORESS is an independent charity, which aims to promote safety in surgical practice in the NHS and the private sector. CORESS receives confidential incident reports from surgeons and theatre staff. These reports are analysed by the Advisory Board, who make comments and extract lessons to be learned. Aiming to educate, and avoid blame, CORESS calls on surgeons to recognise a near miss or adverse event, react by taking action to stop it happening and then report the incident to CORESS so that the lessons can be published. Every month CORESS highlight's one of the cases reported for you to consider the issues raised and read the experts comments. The focus of CORESS is on detecting and learning from no-harm, near-miss and low harm events encountered during routine surgical practice. The programme collects reports of such events, analyses them and disseminates the learning contained within them to a wide surgical audience and other agencies involved in Patient Safety matters. These events are known collectively as ‘Accident Precursor Events’ or simply ‘Precursors’. See previous reports below. Summer 2021 - Unrecognised limb ischemia following trauma, differences of opinion in management for tongue laceration, lack of communication in patient discharge, consequences of service disruption during the COVID-19 Pandemic, systems and communications errors leading to orthopaedic Never Event, too slick by half. Winter 2020 - Missed pulmonary embolism, gastrectomy kit miscommunication, leaking gastrostomy, fatal pulmonary embolus after renal cancer surgery, ureteric injury, PICC line misplacement, CVP line causing haemothorax. Summer 2020 - Thoracic outlet surgery complications, missed breast tumour in pooled case, abscess confusion, injection error, fall from grace, atypical thromboses.

A monthly journal for all operating theatre staff covering surgical and anaesthesia news. 2024 February issue The post-anaesthetic care of a patient following impacted wisdom tooth extraction New Inquiry: NHS Leadership, Performance and Patient Safety Pensioner goes home within hours of having heart valve replacement surgery A student’s Reflection on an experience within the obstetrics theatre Multidisciplinary clinical hub at Cardiff Met offers new vision for healthcare delivery January issue The change in practice of aortic procedures following the introduction of hybrid theatre in a tertiary centre. Evolving heart surgery education is crucial to equip surgeons with the skills to match the technology. A case study detailing the postoperative recovery of an elective patient. Why managing NHS waiting lists is about safety, not just numbers. Keeping an eye on bad behaviour in the operating theatre. Reducing oxygen levels for children in intensive care will save lives, new study shows. Navigating burnout in healthcare: A critical examination of operating theatre staff in the UK. 2023 December issue Royal Papworth patient is first recruit to new ‘blood powder’ heart surgery research trial. A simple guide to the Patient Safety Incident Response Framework (PSIRF). The post-anaesthesia care of an elective inguinal hernia repair patient. Surgical teams at Southmead Hospital carry out 24 robotic-assisted gynaecology procedures in two days. New deep learning challenge to estimate breast density from mammograms. Retained swabs following invasive procedures: Themes identified from a review of NHS serious incident reports. November 2023 Workplace ostracism is clearly associated with healthcare workers’ job satisfaction, stress and perceived health. London operating department practitioner advocacy pilot project. How to share decision-making about major surgery for people at high risk of complications. Proportion of people from Black, Asian and minority ethnic communities registering to donate on the NHS Organ Donor Register is on the rise Trends in cancer. The world’s first collection of brain metastasis living samples will help treat each patient with the most effective therapy for them. Children’s Surgery Magic October 2023 A reflection on my learning as an individual and as part of a team during my second-year anaesthetic placement. Region-wide AI deal to help tackle waiting lists across nine NHS trusts. North Tees and Hartlepool NHS Trust uses RealWear headsets for training. Patients treated sooner thanks to Joint Working to Improve Orthopaedic Care. “Embracing Sustainability in the Operating Theatre: The Shift to Reusable Scrub Caps”. September issue Serious hazards of transfusion (SHOT) report warns of alarming increase in transfusion errors and harm to patients. Doctors cut waiting list for breast cancer surgery patients. Study reveals surgeons need to improve how they communicate with patients about new procedures. Professor Sir Terence Stephenson, "all NHS trusts must use barcodes to locate high-risk devices". Nurses’ intentions to quit increased during the pandemic despite their high resilience. August issue Most common medical claims: How to avoid malpractice allegations. Report recommends packaging and labelling change to prevent implant ‘never event’. New guidance on safe injection practice in hospitals emphasises the importance of prefilled and labelled syringes in avoiding medication errors. Progress with the new hospital programme. Advancements in minimally invasive surgery: Techniques, instruments, and patient outcomes. July issue NHS must accept accountability and learn from mistakes. Simulation based education in healthcare higher education: In what ways does it impact perceived clinical confidence, knowledge, and skills acquisition in student Operating Department Practitioners? Risk reduction in endo-tracheal tube fixation. Historic plan launched to move Wales towards zero deaths from bowel cancer. Taking higher-than-recommended doses of Vitamin D for five years reduced the risk of atrial fibrillation. As complications from cosmetic tourism rise, UK and Turkish plastic surgeons unite to issue consumer guidelines. New research highlights opportunities to improve care of patients having major surgery. June issue How to THRIVE in the Operating Theatre Preoperative optimisation: The effect of prehabilitation interventions on the postoperative recovery of cancer patients undergoing colorectal surgery – Literature review and discussion based paper. Surgeons must tackle three global health challenges to save lives. “PERUSE before you Infuse”. Artificial Intelligence could speed up heart attack diagnosis, SurgiBox: Ukraine’s SurgiBox Project has been successfully demonstrating safe surgery to patients around the world May issue Reducing mortality in emergency surgery: Focussing minds through a national clinical audit in the NHS. Majority of NHS trusts do not offer training to prevent sexual harassment, study finds. Handwashing during ‘normal times’ can reduce burden of respiratory disease. The Surgical Education Checklist as a tool to improve teaching within the operating theatre. April issue NatSSIPs 2 Sequential Steps: The NatSSIPs Eight – Flowchart. Mobile operating theatre helping drive down waiting times in Yorkshire. Why hospitals and ICBs are seeking new intel to find hidden high-risk patients on waiting lists. March issues NHS Scotland first in world to ‘clean up’ anaesthetic gases. New standards to Improve the safety of invasive procedures in the NHS. Researchers suggest novel cutpoints for diagnosing cardiac hypertrophy in adolescents and young adults. NHS patients targeted to reduce risks as they wait for hospital treatment. February New standards to improve the safety of invasive procedures in the NHS. Delphi Study Round Three – A study across NHS England hospital trust operating theatres. Crash and burn(out) – Aviation-style safety checklist and confidential helpline for surgical community to prevent mental health crisis. A Wound Care Study: has the pandemic led to new and improved ways of working? HSIB investigation: Access to critical patient information at the bedside. Artificial intelligence, Patient safety and achieving the quintuple aim in anaesthesiology. January Delphi Study Round Two – A study across NHS England hospital trust operating theatres. Intercollegiate green theatre checklist Local Interventions to support the recovery of elective surgery at the University College London Hospitals department of theatres & anaesthesia. 2022 December issue Delphi Study Round One – A study across NHS England Hospital Trust operating theatres. Managing NHS backlogs and waiting times in England. Steroid injections worsen knee arthritis, according to two new studies. First robotic hysterectomy completed in Wales. World’s first algae-based local anaesthetic another step closer to reality. How new bacterial species siscovered in Asian soil could help battle against antibiotic resistance November issue New research calls for all health and care staff to be trained in AI Reducing noise in operating theatre improves children’s behaviour after surgery, study finds Brain tumour patient operated on awake while playing saxophone No difference between spinal versus general anaesthesia in patients having hip fracture surgery finds study October issue Why are intra-operative surgical Never Events still occurring in NHS operating theatres? Radical rethink needed to improve safety in health and social care. World Anaesthesia Day 2022: History, significance, celebrations and theme. £4 million “space-age” operating theatre will help bring down eye surgery backlog. Two thirds of nurses choosing between food and fuel as cost of living bites and one in five turn to food banks. ‘An inspirational story’: Hartlepool cleaner changes career to become hospital nurse. September issue Service evaluation of the current World Health Organisation’s Surgical Safety Checklist in spine surgery at the University Hospitals of Derby & Burton. Could this lead to a change in NHS Improvement? The Anaesthetic Gas Scavenging System Project. Cancelled operations could be prevented by an earlier anaemia test and time to prepare. The top 10 things experts need you to know about screening during Gynaecological Cancer Awareness Month September 2022 £35.5m for New Friarage Hospital Operating Theatres. New robotic surgical system revolutionises patient care at UHCW. Insourcing: Giving NHS operating theatre teams a helping hand. Arterial stiffness raises blood pressure in adolescents via insulin resistance. Birmingham’s Public Health Chief is among sector leaders to receive university honours,

Surgeons' News is a magazine for surgical, dental and allied healthcare professionals. Published quarterly by the Royal College of Surgeons of Edinburgh, it features comment and opinion from leading professionals, plus reviews and reports on subjects relevant to all career levels.