Sheffield coroner demands NHS answers over death of patient in surgery at Northern General Hospital

Steve Eccleston, assistant coroner for South Yorkshire West, issued a prevention of future deaths report this week (April 15) following an inquest into the death of Craig Burfield in February 2023.

The chief executives of the Sheffield Teaching Hospital Trusts NHS Foundation Trust and the Sheffield Children’s NHS Foundation Trust have 56 days to respond to his findings.

The inquest, which ended on March 26, found that Mr Burfield died at the Northern General from the consequences of clots which formed in his hydrocephaly shunt and cerebral sinus during surgery related to his spina bifida, a condition where the spine doesn’t develop properly.

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He said: “This caused his brain to swell in an unsurvivable event. The cause of the blood clots could not be established on the evidence.”

Mr Eccleston said that Mr Burfield had spina bifida and the shunts were fitted when he was a child – these drain excess fluid from the brain. He had complicated medical needs as a result of his condition.

Consequence

Mr Eccleston said Mr Burfield was admitted for surgery for bladder stones at the hospital spinal injury unit: “He failed to come round from the anaesthetic and died from swelling in the brain as set out above. The cause of the thrombosis could not be established.”

He said evidence from the family and author of an NHS internal investigation, whose name was redacted in his report, showed “it became clear that although Craig had received care for the shunts implanted as a consequence of his hydrocephalus as a young person, this did not continue as an adult.

“Also, there was no process for review of patients such as Craig.”

He said the author of the NHS investigation gave evidence that there is no transfer protocol or pathway in place as children move into adulthood and no effective review process for adults.

Mr Eccleston added: “In evidence, she stated that it was important that a clear pathway, including for transitions between childhood and adulthood, was in place and a failure to have such clear pathways and protocols such that people who needed care could easily access it could potentially be fatal.”