Lynda Pedersen

FAO:  
Patricia Harding 
Senior Coroner 
Cantium House 
Maidstone, Kent 
ME14 1XD 

Dear Madam, 

Regulation 28: Prevention of Future Deaths Report arising from the inquest into the 
death of Lynda Pedersen who died on 7th September 2018 

Thank you for your Regulation 28 Report dated 10th March 2020, revised 15th May 2020 
pursuant to paragraph 7 (1) of Schedule 5 to the Coroners and Justice Act 2009, setting out 
your concerns. 

I would like to begin by expressing to Mrs Pedersen’s family my condolences and on behalf of 
everyone at East Kent Hospitals University NHS Foundation Trust (EKHUFT) for Mrs 
Pedersen’s death. 

I hope that this reply will be helpful in detailing the consideration given and actions taken to 
address the matter of concern in your report, and the ongoing work to make improvements 
within our services. 

Our response to your concern details the actions taken or to be taken. The implementation 
and auditing of this work will be the responsibility of the Trust Board’s Quality and Safety 
Committee. 

Matter of Concern   

Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s 
death. The evidence from the fluid balance charts showed that she was carrying fluids 
forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. 
That there was a significant fluid overload was also evident from the pathology. That she had 
a fluid overload was only identified by the hospital at a time that she was temporally close to 
death. It was accepted at the inquest that the charts were deficient in their completion, that 
nursing staff had not recorded output properly or reconciled the balance as required. 

 
 
   
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Our response 

The Trust is focused on improving how we monitor fluid balance through the completion of 
fluid balance charts in all areas of the Trust. We have addressed this through supporting our 
clinical leadership teams in understanding their roles and responsibilities to ensure best 
practice in their wards by medical and nursing teams. We have undertaken multi-disciplinary 
education programmes on the importance of accurate fluid balance monitoring and regularly 
audit of the completion of fluid balance charts.  
Our Deteriorating Patient Group leads on monitoring audit results regarding accurate 
completion of fluid balance charts with ward managers taking responsibility for their results 
and making improvement where required.  
In addition, all our clinical staff complete clinical induction days to ensure they understand the 
importance of completing fluid balance charts and reviewing these daily and our critical care 
outreach teams provide support and teaching to ward staff on the importance of completing 
fluid balance.  
This concludes our response to your concern.  

We will learn wherever possible from concerns such as this and we will continue working to 
improve the services we offer to the population we serve. I can assure you that East Kent 
Hospital University Foundation Trust Board will be receiving regular updates on the progress 
of the actions set out in this response.  

My thoughts and those of my colleagues at East Kent Hospitals remain with Mrs Pedersen’s 
family and we are very sorry for our failings in her care.  

Yours sincerely 

Chief Executive

Ms Patricia Harding 
Senior Coroner 
Coroner Service Team, 
Cantium House,  
Sandling Road,  
Maidstone  
ME14 1XD 

By email: KentandMedwayAdmin@kent.gov.uk 

Dear Ms Harding, 

National Medical Director 
NHS England & NHS Improvement 
Skipton House 
80 London Road 
London 
SE1 6LH 

5th October 2020 

Re: Regulation 28 Report to Prevent Future Deaths – Lynda Pedersen 

Thank you for your Regulation 28 Report dated 15th May 2020 concerning the death 
of Ms Lynda Pedersen on 7th September 2018. Firstly, I would like to express my deep 
condolences to Ms Pedersen’s family.  

The regulation 28 report concludes Ms Pedersen’s death was a result of complication 
of an undiagnosed but untreatable adenocarcinoma of the oesophagogastric junction. 
The Matters of Concern arising from that inquest are as follows: 

1) Lynda  Pedersen  was admitted  to  William  Harvey  Hospital on  6th September
2017  with  dysphagia.  A  gastroscopy  conducted  two  days  later  identified  a
stricture within the oesophagus with the appearance of the mucosa suggestive
of  a  submucosal  infiltration.  A  CT  scan  did  not  identify  a  malignancy  but
indicated that the area of concern could not be evaluated as it had not been
distended  by  the  orally  ingested  contrast.  Lynda  Pedersen  had  a  number  of
further gastroscopies to attempt to dilate her oesophagus between 2017 and
2018 some of which reported a benign appearance but the cause of the stricture
was  never  investigated  despite  the  risk  of  variceal  bleeding  having  been
significantly  reduced  by  a  TIPS  procedure  having  been  conducted  on  11th
October 2017. It was accepted that a biopsy should have been undertaken but
the need for investigation as to whether there was a malignancy was lost in that
the  clinicians’  focus  was  on  attempting  to  improve  her  nutritional  status  and
quality  of  life.  The  reason  for  the  loss  of  the  need  for  an  investigation  was
twofold: there was no pathway in place for dysphagia presentation caused by
a stricture and the fact of multiple presentations. It was agreed by the treating
clinicians and an independent expert that had there been a pathway in place,
the investigation for cancer was less likely to have been lost. The clinicians who
gave  evidence  at  the  Inquest  were  of  the  view  that  this  was  a  matter  most
appropriately addressed by NHS England and NHS Improvements.

NHS England and NHS Improvement 

 2)  Fluid balance charts were not correctly completed in the period leading to Lynda 
Pedersen’s death. The evidence from the fluid balance charts showed that she 
was carrying fluids forward until the time of her death; there being an imbalance 
to the tune of some 3 1/2 litres. That there was a significant fluid overload was 
also  evident  from  the  pathology.  That  she  had  a  fluid  overload  was  only 
identified by the hospital at a time that she was temporally close to death. It was 
accepted at the inquest that the charts were deficient in their completion, that 
nursing  staff  had  not  recorded  output  properly  or  reconciled  the  balance  as 
required.  

While it is not the role of NHS England and Improvement to develop clinical pathways 
for conditions such as oesophageal stricture, other national bodies have done this. For 
example,  the  British  Society  of  Gastroenterology  2018  guideline  on  managing 
dysphagia  states:  “obtain  biopsies  from  all  strictures  to  exclude  malignancy”  and 
“repeat biopsy after cross-sectional imaging in cases where biopsies are negative but 
clinical or endoscopic features are atypical or suspicious of malignancy”.  

It is common practice for multidisciplinary team meetings to be held to discuss patients 
with  complex  presentations,  such  as  Ms  Pederson,  who  had  dysphagia  but  also 
presented a bleeding risk in view of her liver disease. I would hope that this case has 
been used at the Trust as the basis of reflection, learning and action to reduce the risk 
of a similar situation arising again in the future. 

Thank  you  for  bringing  these  important  issues  to  my  attention  and  please  do  not 
hesitate to contact me should you need any further information. 

Yours sincerely, 

Professor
National Medical Director