Boycie Chatterton: Prevention of future deaths report
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Date of report: 27/11/2023
Ref: 2023-0483
Deceased name: Boycie Chatterton
Coroner name: Bernard Richmond
Coroner Area: Inner West London
Category: Child Death (from 2015)
This report is being sent to: NHS England | Department of Health and Social Care
| REGULATION 28 REPORT TO PREVENT FUTURE DEATHS | |
|---|---|
| THIS REPORT IS BEING SENT TO: Department of Health and Social Care (DHSC) NHS England (NHSE) | |
| 1 | CORONER I am Bernard Richmond KC, HM Assistant Coroner, for the coroner area of Inner West London |
| 2 | CORONER’S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and Regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. |
| 3 | INVESTIGATION and INQUEST An investigation was commenced into the death of Boycie [Alexander/Chatterton], aged 6 weeks. The investigation concluded on 1 September 2023. The conclusion in the inquest was: Complication following surgical procedure The medical cause of death was 1a Hypoxic-ischaemic brain injury 1b. Multiple respiratory arrests 1c. Complications following oesophageal atresia and tracheo-oesophageal fistula repair procedures. 2. VATER association. |
| 4 | CIRCUMSTANCES OF THE DEATH B was born at 36 weeks and 6 days gestation. At birth B was diagnosed with congenital abnormalities including Oesophageal Atresia (OA) and Tracheo-Oesophageal Fistula (TOF), a condition denoted by a blind-ending upper oesophagus with the lower oesophagus connected to the trachea, which affects about 200 babies a year in England. B had an initial surgical procedure to disconnect the TOF and join the oesophagus, but the gap between the two parts of the oesophagus was too great at that time to join. This is known as long gap Oesophageal Atresia (OA), a condition which affects about 20 babies a year in England. Management of long gap OA is very significantly more challenging than non-long gap OA. There are different options for treatment of long gap OA. In this case the surgical team applied tension sutures to draw the oesophageal ends closer for later joining. B had a second planned surgical procedure to check whether the oesophagus was capable of being joined and it was not. At the third planned surgical procedure, an oesophageal anastomosis was performed. Following the third surgical procedure, B developed respiratory complications as a result of which he died. |
| 5 | CORONER’S CONCERNS During the inquest, the evidence revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. 1. I heard from experts giving evidence that the treatment of conditions such as OA with or without TOF would be better served by a properly managed and funded national register for TOF cases, which would in their view likely serve to improve outcomes and survival rates going forward. |
| 6 | ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you have the power to take such action. |
| 7 | YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by 27 October 2023. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise, you must explain why no action is proposed. |
| 8 | COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following: 1. [REDACTED] 2. [REDACTED] 3. Chelsea and Westminster Hospital NHS Foundation Trust 4. TOFS 5. [REDACTED], Birmingham Children’s Hospital 6. [REDACTED], Great Ormond Street Hospital I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any other person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response, about the release or the publication of your response. |
| 9 | 27th November 2023 Bernard Richmond |