Family devastated by mum’s death after routine op
CAROL WAS ONE OF FOUR PATIENTS WHO DIED FOLLOWING THE SAME PROCEDURE – AND CORONER FINDS FAILINGS IN THEIR CARE
A CORONER has issued a prevention of future deaths report after four hospital patients died following a routine procedure.
Nottingham University Hospitals NHS Trust (NUH) had considered all four deaths were unavoidable, Nottingham’s Coroner’s Court heard yesterday.
But Laurinda Bower, assistant coroner for Nottinghamshire, found this was not the case.
She heard evidence from all four cases at a joint inquest between November 15 and December 2.
The patients had all undergone a routine procedure called endoscopic retrograde cholangiopancreatography [ERCP) – which can be used to treat problems in the liver, gall bladder, bile ducts or pancreas and can also remove gallstones.
Carol Cole was one of the patients. She was 55 when she died of an aggressive form of pancreatitis which was probably triggered by the ERCP.
Trevor Cole, who had been married to Carol for more than 20 years, said: “Our whole family is devastated at having to adapt to life without Carol. None of us were prepared for this after the procedure was only a minor, routine operation and I had no idea that she was so dangerously unwell that evening.
“I was in shock when I was told that Carol was gone and can’t remember much after this other than having to break the news to our sons, Ashley and Mitchell. It was one of the hardest things I’ve ever had to do.
“Since her passing, I’ve left my job as a bus driver as it gave me too much time alone with my thoughts, and I’m in the process of moving out of the area, because the house reminds me of Carol.
“It makes me incredibly sad to know that our sons have lost their mum and she won’t see their lives unfold.
“She was taken from us far too soon and will be missed by everyone who knew her. To me, she was perfect and I will never forget her.”
Emily Rose, a solicitor who specialises in medical negligence and inquests at Nelsons, has been assisting Mr Cole and his family in preparation for the inquest.
She said: “During her procedure, the guidewire that was inserted entered the pancreatic duct twice. While this complication can happen, the fact that Carol developed such a severe case of pancreatitis soon after is incredibly concerning – especially given how quickly she was discharged combined with the circumstances surrounding the three other patients who also passed away following this procedure. There were also criticisms raised in relation to the ambulance service, which caused further dis
tress to Carol and Trevor.
“Today’s conclusion found that Carol died as a result of complications of the ERCP procedure and that her death was not natural. While it was found that an earlier arrival at the hospital would have been unlikely to extend her life for much longer, the coroner did identify that there was a failure to appreciate how unwell Carol was when she arrived and that, had this been identified, she would have been managed more appropriately.
“The coroner highlighted that, while the initial cause for concern was that all four deaths had happened at the hand of the same trainee, the evidence presented has revealed that the issue is more with the system in place for patient triage, rather than any technical incompetence of any individuals.
“While today’s findings will not be able to fill the hole that losing Carol has left, I hope that it has gone some way to providing the answers Trevor and his family thoroughly deserve, and lessens the chances of a similar situation occurring in the future.”
Another patient who died was William Doleman. He was 76 when he died at the Queen’s Medical Centre on April 1, 2020.
It was likely he suffered a perforation near the end of the procedure.
Miss Bower said it was likely there were two missed opportunities to have investigated, diagnosed and treated the perforation.
He was told there was a stone in his bioduct and an endoscopist was going to remove it – but he should have been told he probably did not have a stone. The fact he was told it needed to be removed was not an accurate representation, the inquest heard.
The coroner said he should have been counselled for the need for further imaging to confirm the diagnosis and his consent was based on inaccurate information. A narrative conclusion was given in his case.
It was found that there were systemic issues with regards to patient triage.
Anita Burkey was 85 when she died as a result of complications after her ERCP and she had a perforation.
The coroner said her case highlighted again the impact of information and vetting and said: “I find her death and timing of her death should and could have been avoided.”
The fourth patient, Peter Sellars, 72, died at the QMC as a result of a complications of pancreatitis after the procedure.
Ms Bower was concerned by the lack of a formal action plan for change after she said the trust’s position was that there were no lessons to be learned.
One doctor, who assisted the inquest with his opinion, said there should have been a personalised approach regarding the patients who underwent the procedure, some with existing medical problems which had not been flagged up.
The coroner said the personal approach was “what was missing in all these four cases”.
She will issue her report to the Trust’s chief executive, so action can be taken, and share her of her findings to the British Society of Enterology on the prevention of future deaths.
She said the Trust are required to write to her to inform her of what action it plan to take.
John Walsh, Deputy Medical Director at NUH said: “We would like to offer our sincerest condolences to the families for their loss and we are truly sorry for any shortcomings in the care we provided.
“Although each case is unique, we should have done more to involve families in decisions about patient care as well as taken other actions to manage these complex, high-risk cases.
“We have made significant changes to a number of our Trust policies and processes in these areas, including a review of, and changes to when and how we declare a Serious Incident, to ensure that patients undergoing an ERCP procedure receive the appropriate and timely care they need.”