Inquest into the death of Kelvin MOULDS

61y · Male·Hypoxic encephalopathy arising from cardiac arrest following self-removal of a central venous catheter

Kelvin Moulds, a 61-year-old man, died of hypoxic encephalopathy following a cardiac arrest caused by self-removal of a central venous catheter (CVC) on day 14 post-bilateral lung transplant. The CVC was still in situ despite two documented orders for removal on 3 March 2016. Clinical lessons include: (1) delirium was recognised but inadequately treated—Haloperidol was recommended but not charted; (2) communication breakdown between medical and nursing staff regarding CVC removal; (3) lack of monitoring for delirium despite recognised risk; (4) delayed CVC removal in the ward setting increased air embolism risk. St Vincent's Hospital implemented substantial changes including preferring PICC lines, treating delirium as a red flag for CVC removal, improved delirium screening protocols, and enhanced nurse training on vascular access device management. Earlier recognition and treatment of delirium, clear escalation pathways for CVC removal decisions, and closer monitoring of delirious patients could have prevented this death.