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Mencap urges medics to improve care of patients with disabilities
Mencap urges medics to improve care of patients with disabilities

BBC News

time22-03-2025

  • Health
  • BBC News

Mencap urges medics to improve care of patients with disabilities

Greater awareness is needed in how to treat people with disabilities after a man died in a hospital following complications from kidney dialysis, a charity Tooke, 30, from Norwich, died in August after a line from a dialysis machine became detached, causing an air embolism that triggered a fatal brain Tooke's mother, Camilla Tooke, believed her son had been subjected to discrimination at the hospital based on his disability and questioned whether doctors had done all they could to save his life. Jon Sparkes, the chief executive of Mencap, said: "All healthcare professionals should receive training to ensure unbiased decision making." The Norfolk and Norwich University Hospital, which treated Mr Tooke, said: "We are committed to provide the best care for people with a learning disability and autistic people and to make adjustments when necessary to access the care they need." Mr Tooke had Williams Syndrome - a condition affecting development - and autism. He was non-verbal and had learning was later diagnosed with chronic kidney disease and a Court of Protection order led to him being put on the inquest into Mr Tooke's death, Ms Tooke said following her son's embolism, "Dr Fletcher [the head intensive care consultant] said 'well, what quality of life does he have anyway?'"I knew the question of DNR [do not resuscitate] was coming, so I said: 'You can't ask me to make that decision,' to which he replied, "you won't make that decision. I will."At the inquest Dr Simon Fletcher apologised to Ms Tooke, claiming she had misunderstood his comments and that he had not acted in a discriminatory manner. Dr Fletcher told the inquest he had intended the question to ascertain Mr Tooke's quality of life prior to the embolism, in order to assess whether treatment might have left him in a permanent vegetative said: "He'd suffered a catastrophic brain injury and one of the difficulties of critical care is there are two difficult aspects; the decision of when people are going to benefit... and second is when enough's enough."Critical care is not without real difficulties for the patient physically and psychologically so I always like to understand what the quality of life for the patient was before that and I was asking that only to establish, not as a judgemental issue." Mr Sparkes, from Mencap, added: "Jordan's family battled tirelessly to ensure their 30-year-old son could access treatment."All healthcare professionals should receive training to ensure unbiased decision making and ensure all NHS providers are making reasonable adjustments so people with a learning disability can access adequate care."No family should ever have to ask if the NHS is doing everything that they can to save their son." Rachael Cocker, the chief nurse at the hospital, said: "Our deepest condolences are with Jordan's family following their loss."Our clinicians and learning disabilities team at NNUH worked closely with Jordan and his family to make adjustments to enable him to receive dialysis with the aim of him receiving a kidney transplant in the future."Our teams were devastated by Jordan's death and are committed to learning from what happened."The Oliver McGowan Mandatory Training on learning disability and autism has been embedded across our trust to ensure all staff have the skills to provide appropriately adjusted care for people with a learning disability and autistic people to reduce health inequalities." Follow Norfolk news on BBC Sounds, Facebook, Instagram and X.

Man died after air bubble entered vein in dialysis
Man died after air bubble entered vein in dialysis

Yahoo

time19-03-2025

  • Health
  • Yahoo

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 - who had been sedated - fell 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. Follow Norfolk news on BBC Sounds, Facebook, Instagram and X. Mum overjoyed at 'life and death' court win for son Dialysis failures put 15 patients in hospital Norfolk Coroner's Court

Norwich man died after air bubble entered vein in dialysis
Norwich man died after air bubble entered vein in dialysis

BBC News

time19-03-2025

  • Health
  • BBC News

Norwich 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 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 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 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 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 a witness statement, Jordan's mother Camilla Tooke said her son - who had been sedated - fell asleep during the dialysis 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 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 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 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 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. Follow Norfolk news on BBC Sounds, Facebook, Instagram and X.

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