A PREVENTION of Future Deaths report following the death of a man from Redruth has criticised staff at the hospital where he was treated after they failed to pass on critical information that could have saved his life. 

Ian Jacka, aged 51, from Redruth, died on June 15, 2022, at Derriford Hospital Plymouth from complications following surgery for trauma. On June 3, 2022, Ian fell from an unofficial pathway into the National Trust car park at Chapel Porth. Ian fell so that he landed in front of the toilet block in the car park, suffering very serious injuries including several fractures to his skull, brain, and ribs, as well as spinal injuries.

An inquest was held into Ian's death on November 7, 2023, and found that, the day after being transferred from the Royal Cornwall Hospital Trust to Derriford Hospital for treatment of complex spinal fractures, on June 5, 2022, Ian suffered a medical episode which developed into a critical incident during which Ian deteriorated rapidly and required life-saving measures.

According to Coroner Guy Davies, Assistant Coroner for Cornwall & the Isles of Scilly, during the course of the inquest, evidence revealed matters giving rise to a risk that future deaths will occur unless action is taken.

The coroner noted that among the concerns were:

  • There was an error of omission in record keeping and in handover from critical care to surgery, and this error likely contributed to Ian’s death.
  • There was no entry in Ian’s hospital notes to indicate the full extent of the critical incident of 5 June 2022.
  • There was a lack of information on handover from critical care to the surgical team regarding the full extent of the critical incident of the 5 June 2022. There was a verbal handover which was brief and vague. There was no formal written handover process highlighting significant events.

According to the Prevention of Future Deaths report produced by the coroner: "The error of omission was unexplained and has not been investigated by the NHS. The evidence regarding the error of omission came to light after the completion of the NHS investigation into Ian’s death.

"The Consultant Anaesthetist involved in Ian’s operation discovered the fact of the critical incident of 5 June 2022 on a later examination of ventilator data. The data indicated that Ian deteriorated significantly, that he was close to a cardiac arrest and the critical care team saved his life.

"The surgical and anaesthetic team had no reason to suspect a secondary brain injury. The team had no information on Ian’s neurological status. Ian is likely to have suffered a hypoxic brain injury during the critical incident of 5th June. This will have undermined his resilience and ability to physically withstand the rigors of spinal surgery and airway exchange.

"Had the surgical and anaesthetic team known of the extent of the critical incident of 5 June, the operation would have been delayed and further tests and assessments undertaken. The anaesthetic team may have opted for elective tracheostomy if the full circumstances of the critical incident of 5 June 2022 had been known. An elective tracheostomy would have led to
a different outcome because it would have avoided the complications that ensued from the attempted airway exchange.

"I note the NHS Investigator and the Investigatory Panel both recommended that action is required for the handover of complex patients. The panel recommended as follows:
More robust and formalised handover of complex patients before transfer to theatre, to include review of airway management, cardiopulmonary status, potential avenues of deterioration and any significant events during admission

"The Trust had chosen not to accept this recommendation but at the time the Trust made that decision it was not aware of the extent and significance of the error of omission."

The panel recommended the following changes but put into place: "More robust and formalised handover of complex patients before transfer to theatre, to include review of airway management, cardiopulmonary status, potential avenues of deterioration and any significant events during admission."