Catheter error which killed patient at Yorkshire hospital could claim more lives, coroner warns

Maxwell Frame suffered a fatal stroke which was caused by a clot that formed when a central venous catheter was mistakenly inserted into his artery at Huddersfield Royal Infirmary in June 2021.

An inquest was told NHS staff failed to undertake a series of checks to ensure the tube had been inserted correctly.

Coroner Peter Merchant, who conducted the inquest, has written to the Department for Health and Social Care, urging it to introduce national policy on placing central venous catheters to ensure all NHS staff are following the correct procedure.

“In my opinion there is a risk that future deaths could occur unless action is taken,” he wrote in a report.

Mr Frame was admitted to A&E at Huddersfield Royal Infirmary in June 2021, as he was suffering with sepsis after his appendix perforated and an abscess formed in his pelvis.

Surgeons drained the abscess, removed the appendix, which had become gangrenous, and cleared a blockage in his bowel.

While he was being treated, medical staff attempted to insert a catheter into his right subclavian vein so it could be used to administer fluids, medications and blood, but they put it into an artery.

In his report, the coroner medical staff should have used an ultrasound to ensure the tube was being placed correctly, and been monitoring the levels of oxygen and carbon dioxide in his arteries.

Staff did conduct a chest x-ray to check on the placement of the tube, but incorrectly concluded the tube had been inserted into a vein.

When they realised their mistake three days later, Mr Frame was transferred to Bradford Royal Infirmary so he could undergo a procedure to have it removed.

But while he was being treated a blood clot attached to the catheter dislodged and caused an embolism to form in his brain.

He suffered a severe stroke and was pronounced dead on July 13 in 2021, after his family agreed to withdraw palliative care.

Brendan Brown, Chief Executive of Calderdale and Huddersfield NHS Foundation Trust, said: “I would like to once again offer our sincere apologies and heartfelt condolences to Mr Frame’s family and friends.

“The inquest process has taken a long time and we appreciate that it will have been distressing for Mr Frame’s family.

“We fully accept the Coroner’s findings and have taken steps to embed the lessons learned from Mr Frame’s sad death.”

The Department of Health and Social Care has 56 days to respond to the coroner’s report.