Prevention of Future Deaths reports · 2015
Regulation 28 report to prevent future deaths, reference 2016-0117, written 22 Dec 2015. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 22 Dec 2015 |
|---|---|
| Reference | 2016-0117 |
| Deceased | Shalini Ganesh-Ram |
| Coroner | Mary Hassell |
| Coroner area | Inner North London |
| Category | Hospital Death (Clinical Procedures and medical management) related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | none published |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: Prevention of Future Deaths report
Shalini GANESH-RAM (died 11.08.15)
THIS REPORT IS BEING SENT TO:
1.
Acting Medical Director
Barts Health
Royal London Hospital
Whitechapel Road
London
E1 1BB
1
CORONER
I am: Coroner ME Hassell
Senior Coroner
Inner North London
St Pancras Coroner’s Court
Camley Street
London N1C 4PP
2
CORONER’S LEGAL POWERS
I make this report under the Coroners and Justice Act 2009,
paragraph 7, Schedule 5, and
The Coroners (Investigations) Regulations 2013,
regulations 28 and 29.
3
INVESTIGATION and INQUEST
On 17 August 2015, I commenced an investigation into the death of
Shalini Ganesh-Ram. The investigation concluded at the end of the
inquest on 17 December 2015.
I made a narrative determination, which I attach.
4
CIRCUMSTANCES OF THE DEATH
Ms Ganesh-Ram died in the Royal London Hospital on Tuesday, 11
August 2015, having suffered a perforated caecum.
1
On Thursday, 6 August, she underwent a Caesarean section.
Unbeknown to anyone at the time, she immediately developed Ogilvie’s
syndrome, a very rare complication of Caesarean section. On Saturday,
8 August, this acute pseudo obstruction of the bowel led to a perforated
caecum. And on Monday, 10 August, the perforation was diagnosed and
a left hemi colectomy was performed.
However, she was by then in extremis, and died the following day.
5
CORONER’S CONCERNS
During the course of the inquest, the evidence revealed matters giving
rise to concern. In my opinion, there is a risk that future deaths will occur
unless action is taken. In the circumstances, it is my statutory duty to
report to you.
The MATTERS OF CONCERN are as follows.
I heard at inquest that Ogilvie’s syndrome is an extremely rare
complication of a Caesarean section, and it would be highly unlikely that
any clinician would suspect this in the first instance.
However, when Ms Ganesh-Ram’s caecum perforated, which with
hindsight was probably two days post operation, the perforation was not
diagnosed and a surgical consultation not sought until four days post
operation.
From the evidence I heard, it seems that a number of issues would
benefit from your consideration.
1. Whilst Ms Ganesh-Ram underwent many consultant reviews, a
raised pulse, abdominal pain and lack of urine output on Saturday
the 8th and the morning of Sunday the 9th did not prompt a CT
scan.
Reassurance was drawn from the fact that her pain was controlled,
but I wonder whether this was false reassurance, given that it was
controlled by Oramorph, dihydrocodeine and paracetamol.
(Abdominal distension was not noted until the middle of the day on
Sunday the 9th, probably because it was masked by a high body
mass index.)
2. When a plan was made at 1.30pm on Sunday the 9th for a CT
scan, this was not performed and reported on until approximately
7.30pm that evening.
2
3. Several obstetric registrars were aware that the CT scan revealed
a large volume in the peritoneum, but did not then seek a surgical
consult, perhaps because the radiology registrar described no
bowel wall defect having been demonstrated.
I heard that the report of the radiology consultant the following day
was felt to provide a clearer warning of perforation.
4. Your own serious incident report has already identified other
issues around service delivery, most particularly that the modified
obstetric early warning score tool was not used appropriately to
identify Ms Ganesh-Ram’s sepsis.
It seemed from the evidence I heard at inquest, that Ms Ganesh-Ram’s
sub optimal care was not the result of the actions of one individual, nor
even of several individuals, but of many individuals and the system within
which they were working.
Optimal care may not have saved Ms Ganesh-Ram’s life. Indeed, given
a body mass index of 55, I was told that death was a likelihood from the
moment her caecum perforated. However, earlier diagnosis and
appropriate treatment would have afforded her a greater chance of
survival than she had on Monday, 10 August.
6
ACTION SHOULD BE TAKEN
In my opinion, action should be taken to prevent future deaths and I
believe that you and your organisation have the power to take such
action.
7
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date
of this report, namely by 29 February 2016. I, the coroner, may extend
the period.
Your response must contain details of action taken or proposed to be
taken, setting out the timetable for action. Otherwise you must explain
why no action is proposed.
8
COPIES and PUBLICATION
I have sent a copy of my report to the following.
3
HHJ Peter Thornton QC, the Chief Coroner of England & Wales
Care Quality Commission for England
, consultant obstetrician and gynaecologist
husband of Shalini Ganesh-Ram
I am also under a duty to send the Chief Coroner a copy of your
response.
The Chief Coroner may publish either or both in a complete or redacted
or summary form. He may send a copy of this report to any person who
interest. You may make
he believes may
representations to me, the Senior Coroner, at the time of your response,
about the release or the publication of your response by the Chief
Coroner.
it useful or of
find
9
DATE SIGNED BY SENIOR CORONER
22 December 2015
4
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