Prevention of future deaths report following the inquest into the death of Alexandra Briess

Following the conclusion of the inquest into the death of Alexandra Briess, the coroner has issued a prevention of future deaths report. 

Prevention of future deaths reports are written when the coroner has heard evidence that further deaths might happen if action is not taken to prevent this. The report is sent to those with the power to make the changes needed. They must reply within 56 days saying how they plan to respond. 

Alexandra, who was just 17 years old at the time of her death, died on 31st May 2021 at the Royal Berkshire Hospital in Reading. She was undergoing a routine procedure to address bleeding following a tonsillectomy the week before. Alexandra suffered anaphylaxis to one of the routine anaesthetic medicines (Rocuronium), which led to a cardiac arrest from which she tragically could not be resuscitated.

Heidi Connor, Senior Coroner for Berkshire, has issued a prevention of future deaths report to address concerns that information about fatal cases of anaphylaxis is not gathered nationally, to improve understanding and prevent or reduce further deaths.  

The matters of concern raised include:

• To consider creation of a leadership role within NHS England to take responsibility for and coordinate a national approach to gathering information and funding research into anaphylaxis.
• Making it mandatory for doctors to refer fatal anaphylaxis cases to the UK Fatal Anaphylaxis Registry (UKFAR).
• Consideration of including contact details for the UKFAR in algorithms used by doctors attempting to resuscitate patients to ensure reporting.
• Funding the UKFAR to ensure that these measures can be implemented.

The coroner highlighted that these matters of concern have already been raised in at least three previous prevention of future deaths reports, including those of Celia Marsh, Ruben Bousquet and Shante Turay-Thomas. Despite this, action has still yet to be taken.

This report has been sent to Secretary of State for Health and Social Care, Steve Barclay who has 56 days to respond.

Simon Williams, chief executive of Anaphylaxis UK, said: 

“Anaphylaxis UK would once again like to extend our deepest sympathies to Alexandra’s family. We support the need for a mandatory reporting system to record information about anaphylaxis cases to help understand the causes behind anaphylaxis-related deaths and how to prevent future early deaths. We echo the repeated calls for increased funding for the UK Fatal Anaphylaxis Registry (UKFAR) to help meet this aim. ”