Man died after air bubble entered vein in dialysis

A disabled man died after an air bubble got into a vein when his dialysis line detached from the machine.

Norfolk Coroner's Court heard Jordan Tooke, 29, from Norwich, was in good health and spirits when he arrived for his routine treatment at the Norfolk and Norwich University Hospital on 28 August.

But about an hour into the treatment for acute kidney disease, his mother noticed blood.

None of the medical team that treated him could explain how the central venous catheter became uncoupled, but an embolism triggered a sequence that caused him to die on 31 August. Area coroner Johanna Thompson recorded a conclusion of accident.

Mr Tooke had Williams Syndrome - a condition affecting development - and autism. He was non-verbal and had learning disabilities.

He was born with one small kidney and the other was found to contain a cyst, but as a small child he had normal liver function.

He was later diagnosed with chronic kidney disease and a Court of Protection order led to him being put on dialysis.

Norfolk Coroner's Court heard how an hour into a routine dialysis appointment the line into Mr Tooke's vein had detached, causing him to bleed and an air bubble to enter his vein.

Although his post-mortem examination showed the cause of death as bronchopneumonia, the court heard he had suffered a "cardiac standstill" as a result of the embolism, which led to a catastrophic brain injury.

In a witness statement, Jordan's mother Camilla Tooke said her son had fallen asleep during the dialysis process.

She said: "As I looked at him, I noticed that there was blood and shouted 'blood' to Sarah [Jordan's main carer] and I immediately applied pressure."

The emergency alarm was activated, and staff arrived and reconnected the line but were unsure how the connection had become undone.

Later in the day, he underwent a CT scan, which found no evidence of air in his veins, but intensive care consultant Dr Simon Fletcher said this could have been absorbed into his body.

Mrs Tooke added: "We were left alone with Jordan and he didn't seem to be getting any better. I was concerned that no-one had explained the consequences of the disconnection.

"Later in the day, Jordan's right eye became closed and I thought he might have had a stroke and his leg had become unresponsive, and I said something wasn't right.

"The nursing staff couldn't understand as his vital signs were OK, so it seemed to be no issue.

"I believe the nursing staff did their best for Jordan, but it was obvious what was happening was beyond their expertise and the doctors didn't seem concerned."

In evidence, matron Sarah Trudgill said her team was devastated by Jordan's death, but there was no damage or explanation as to why the line had become detached.

Nurse Hannah Filby, a deputy sister on Langley Ward renal unit, said with 13 years' experience she could not understand or explain how the line became detached, saying she had never seen it happen before.

"I could not see how that could have come off on its own," she said.

"Jordan had never, in my experience, fiddled with his line. If it was out of sight, it was out of mind, which is why we covered it."

Dr Ravi Varma, a primary renal consultant, said: "There were signs that [an embolism] had happened. The drop in blood pressure, the mottling of the skin, the change in his behaviour and the concerns a stroke was occurring."

He also said there was a possibility food from the stomach entered Mr Tooke's lungs, causing inflammation leading to bronchopneumonia.

Dr Varma added: "He was well before dialysis, but there became a detachment [of the line] and he became unwell thereafter."

Coroner Johanna Thompson said the primary cause of death was brain damage caused by an air embolism, but that no evidence could explain how the line had become disconnected, adding: "This was an accidental event."

She said she would not file a Prevention of Future Deaths report because the Norfolk and Norwich University Hospital was working on amending its procedures to treat patients with an air embolism, as a result of the death.

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