An inquest into the death of Desline Menezes highlights the hazards involved in the removal of Central Venous Catheter (CVC) lines.
Desline Menezes was 16 at the date of her death. Last December she was admitted to St George’s Hospital for treatment of her Myasthenia Gravis – a neurological disease. A CVC line was placed into a vein in her neck as apart of her treatment. Just before her intended discharge from hospital the CVC line was removed by a nurse on the ward.
Desline’s uncle gave evidence at the inquest that the line was removed while Desline was sitting up by her bedside and the nurse did not use an airtight dressing to cover the line’s exit point. About 10 minutes afterwards, Desline collapsed with breathing problems. Sadly, she did not recover and she died the next day.
The family suspected that there was a connection between the way that the line had been removed and her collapse. The Coroner called doctors from the Trust and heard evidence from them whether the removal of the line was implicated in her death.
It has been known for many years that removal of these lines is an opportunity for injury by air entry into the circulation. To minimise the risk of this happening, nursing and medical guidance is to remove the line with the patient in a Trendelenburg position (ie, lying with head slightly lower than feet) while the patient performs the Valsalva manoeuvre and to ensure that the wound is covered with an air-tight dressing. Sadly, the Coroner heard evidence that the line was removed in an incorrect manner against the hospital’s policy. The Coroner concluded that Desline’s death was connected with the removal of the line and entry of air into her circulation.
The Trust carried out a Serious Untoward Incident investigation following Desline’s death during which it emerged that there had been two similar “near misses” at St George’s Hospital in previous years. We now hope that the staff who carry out the removal of these lines at St George’s Hospital have been reminded of the correct procedures in order to avoid any further fatalities or injury.
For more information please contact
Henry Dyson on 020 7650 1200.
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