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Quick Tip for Families in Intensive Care: My Son Died in Intensive Care After a Blocked Tracheostomy, Should I Get a Medical Record Review?

Hi, it’s Patrik Hutzel from intensivecarehotline.com with another quick tip for families in intensive care.

So today, I have a question from Sue who writes in,

“Hi Patrik,

My son died in ICU when the nurses had his bed around the wrong way and didn’t monitor him. He died of a hypoxic brain injury as his tracheostomy got blocked when they were changing shifts and didn’t monitor him after we had left. We had to get the nurse to clear his tracheostomy three times during that day. Unfortunately, this happened after we had gone home so we couldn’t get help.

He was getting better, and they were going to remove the tracheostomy the next day as all his vital signs were good. They have not given an explanation and the coroner said he died from a fungal infection.

When we questioned this, they said that they had no information from ICU, only from his admission. We know he died from his brain injury due to the blocked tracheostomy, but they will not admit it.

Also, they were supposed to put a cold blanket under him and above him to try and preserve his brain. He knew we were there when we arrived an hour after the incident. They only put this blanket on top of him and put the other one in the cupboard.

I’m writing this as a warning against ICU nurses who do not monitor 24 hours a day and spend most of their time on their phones. I have lost two sons to bad ICU care. I am devastated.

Thank you, Patrik, for the help you are giving to families with loved ones in intensive care. They must listen to you.

Kind regards with a heavy heart.

From, Sue.”

Sue, I’m very sorry to hear what you are dealing with.

I have worked in critical care/intensive care for nearly 25 years in three different countries where I worked as a nurse manager for over 5 years and where I’ve been consulting and advocating for families in intensive care since 2013 here at intensivecarehotline.com.

Now, I’m gobsmacked by what I’m hearing here. Like, I have certainly heard of tracheostomy being blocked outside of ICU without ICU nurses, which is why someone with a tracheostomy should never leave ICU unless they’re going in a home care environment with Intensive Care at Home, and you can find more information at intensivecareathome.com. So, I am gobsmacked that your son had a blocked tracheostomy, and they couldn’t manage that in ICU. It’s almost unheard of.

I have heard of a case maybe two years ago in Sydney, Australia where a hospital had a similar situation and I actually think they lost some of their accreditation status within that hospital because of the incident that happened there with the blocked tracheostomy in ICU.

So, any blocked tracheostomy that I have seen in ICU can be managed because you’ve got all the skills, all the expertise, you’ve got all the equipment there to manage a blocked tracheostomy. So technically, he was in the most safe environment, but obviously, you’re saying that nurses were spending time on their phones. There could also be a case of staff shortages on that shift. What I’ve seen in ICU over the years is some days you might have such a staff shortage that you get a ward nurse or a regular nurse into ICU from a regular ward and they seem they haven’t worked in ICU, but sometimes that’s what you have to do. But you wouldn’t give them a patient with the tracheostomy because you would give them the lowest acuity patient and look after the patients that will be discharged to a ward or to a hospital floor anyway. You wouldn’t get them to look after a tracheostomy, but obviously something awful happened here and it could simply be the way they’re running the place, the way they’re running the ICU. It definitely needs to be investigated.

Now, I wouldn’t take for face value what the coroner says. What I would do if I was you, I would get access to all of the medical records and I mean, all of them, not a single page missing and get us to look at them. We do medical record reviews here at intensivecarehotline.com to look for medical negligence, or if you have questions, if families need closure, we can provide all of that.

We also provide medical record reviews in real time so that you can get a second opinion in real time, but I wouldn’t rely on the coroner here. I would take matters into my own hands if I was you and go from there. Obviously, it’s interesting that you said you have to get the nurse to clear his tracheostomy three times during the day. What does that mean? Does that mean they have to suction him three times a day? Does that mean they had to change the tracheostomy tube three times a day? Does it mean they change the inner cannula or the inner tube? Many tracheostomies have an inner cannula or inner tube, what are you referring to?

Again, the biggest challenge for families in intensive care is that they don’t know what they don’t know. They don’t know what to look for. They don’t know what questions to ask. They don’t know their rights and they don’t know how to manage doctors and nurses in intensive care. I think that’s part of the problem here that, what does it all mean and what has led up to it?

With the cooling blanket, it also sounds to me like he might have had a cardiac arrest probably after the blocked tracheostomy; that is a possibility. They should have definitely cooled him after that, usually for 24 to 48 hours, usually down to a temperature of 33 to 34°C. And yes, that usually takes a blanket on top and the bottom to achieve that cold temperature.

So, my advice here really is to let us do a medical record review and dig to the bottom of things and then we can go from there.

Because we get so many questions from families in intensive care every day, this is actually a question from December last year. That’s how many emails I’ve got sitting in my inbox and I’m just getting to now. If you want to have things addressed like that quickly, always contact us intensivecarehotline.com directly. It’s best to call us on one of the numbers or send us an email to [email protected].

Another quick way to get your email answered is just make a small donation with a super chat button on YouTube and I will read out your email pretty quickly. A small donation always helps. The more content we can create for families in intensive care, the more people we can help. It takes an army to change the world, as they say.

We also have created an online membership for families of critically ill patients in intensive care and you can become a member if you go to intensivecarehotline.com if you click on the membership link or you go to intensivecaresupport.org directly. In the membership, you have access to me and my team, 24 hours a day, in the membership area and via email, and we answer all questions intensive care related. In the membership, you also have exclusive access to 21 eBooks and 21 videos that I have personally written and recorded from all my nearly 2.5 decades worth of ICU nursing experience and you will make informed decisions, have peace of mind, control, power, and influence so that your loved one gets best care and treatment. When you read those eBooks and you get your questions answered in the membership, it will make all of the difference.

We have helped thousands of families of critically ill patients in intensive care. We have saved lives with our consulting and advocacy. You can verify that on our testimonial section or if you go to our podcast section at intensivecarehotline.com and listen to some of our client interviews what they say.

I also do one-on-one consulting and advocacy over the phone, Skype, Zoom, WhatsApp, whichever medium works best for you. I talk to you and your families directly. I handhold you through what is a very traumatic and once in a lifetime experience that you can’t afford to get wrong. Once again, if I talk to you and your families directly, I’ll make sure you make informed decisions, have peace of mind, control, power, and influence. I also talk to doctors and nurses directly on your behalf if that’s what you want me to do. I ask all the questions that you haven’t even considered asking but must be asked when you have a loved one critically ill in intensive care.

I also represent you in family meetings with intensive care teams. Once again, making sure you make informed decisions, you have peace of mind, control, power, and influence, making sure your loved one gets best care and treatment.

We also do medical record reviews in real time so that you can get a second opinion in real time. We also offer medical record reviews after intensive care if you have unanswered questions, if you need closure, or if you are suspecting medical negligence.

All of that you get at intensivecarehotline.com. Call us on one of the numbers on the top of our website or send an email to [email protected] with your questions.

If you like my videos, subscribe to my YouTube channel for regular updates for families in intensive care. Click the like button, click the notification bell, share this video with your friends and families, and comment below what you want to see next, what questions and insights you have from this video.

I also do a weekly YouTube live where I answer your questions live on the show and you will get notification for the YouTube live if you are a subscriber to my YouTube channel or if you are a subscriber to our email newsletter at intensivecarehotline.com.

Like I said, if you make a small donation with the super chat button here on YouTube, I get your email pretty quickly, or if you want to just make a small donation to help us out, the more content we can make for families of critically ill patients in intensive care.

Thank you so much for watching.

This is Patrik Hutzel from intensivecarehotline.com and I will talk to you in a few days.

Take care for now.