Sheffield coroner demands NHS answers over man's death

The hospital has been given 56 days to respond to the coroner's warning

The death of a man from swelling to his brain during surgery at the Northern General Hospital in Sheffield has drawn a warning from a coroner.

An inquest heard that Craig Burfield died in February 2023 from the effects of clots which formed in his hydrocephaly shunt and cerebral sinus during surgery related to his spina bifida.

Whilst the cause of the blood clots was not established, the coroner's report pointed to risks through adult patients not being monitored for potential problems from shunts, something that did happen during childhood.

Both Sheffield Teaching Hospital Trusts NHS Foundation Trust and the Sheffield Children’s NHS Foundation Trust have 56 days to respond to the coroner's findings.

'Swelling in the brain'

Steve Eccleston is assistant coroner for South Yorkshire West, and he has issued a prevention of future deaths report.

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.

Mr Eccleston said that Mr Burfield was admitted for surgery for bladder stones at the hospital spinal injury unit.

He said: “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 the author of the NHS investigation into the death gave evidence that there was no transfer protocol in place as children moved 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.”

In response to a request for comment on the coroner's report, both Sheffield Teaching Hospitals and the Sheffield Children's Hospital told the BBC that they were still working jointly on the points raised by the coroner and are not in a position to say more until that work is complete.