Prevention of Future Deaths reports · 2021

Prevention of Future Deaths report 2021-0432

Regulation 28 report to prevent future deaths, reference 2021-0432, written 23 Dec 2021. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.

Date of report23 Dec 2021
Reference2021-0432
CoronerLaurinder Bower
Coroner areaNottingham City and Nottinghamshire
CategoryHospital Death (Clinical Procedures and medical management) related deaths
Organisation namedNottingham University Hospitals NHS Trust
Sourcejudiciary.uk record · original PDF
Responses published1

The report

Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.

Regulation 28: REPORT TO PREVENT FUTURE DEATHS 

NOTE:  This form is to be used after an inquest. 

REGULATION 28 REPORT TO PREVENT DEATHS 

THIS REPORT IS BEING SENT TO:  

1  Chief Executive, Nottingham University Hospitals NHS Trust 

1  CORONER 

I am Miss Laurinda Bower , HM Assistant Coroner for the coroner area of Nottingham City and 
Nottinghamshire 

2  CORONER’S LEGAL POWERS 

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and 
regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 

3 

INVESTIGATION and INQUEST 

I commenced investigations into the deaths of William DOLEMAN, Anita BURKEY, Peter 
SELLARS and Carol Christine COLE.  The investigation concluded at the end of the inquests, 
heard together, between 15 November 2021 and 17 December 2021.  The conclusion of the 
inquests were as follows: 

“Bill died on 1 April 2020, at the Queens Medical Centre, Nottingham, as a result of medical 
complications following an ERCP procedure performed on 19 March 2020, in which he 
suffered a recognised complication, namely a perforation to his duodenum, likely caused as a 
result of catheter trauma. 
At the time, the procedure was not clinically indicated, and ought not to have gone ahead. If 
the procedure had been postponed for further imaging, Bill would not likely have died when 
he did and in the manner that he did. 
Failures in his pre-procedure care directly contributed to his death. 
There were missed opportunities to have diagnosed and treated Bill’s perforation during the 
procedure, and while this would likely have reduced his risk of dying, it might not have 
prevented his death.” 

“Anita died on 5 April 2020, at the City Hospital, Nottingham, as a result of medical 
complications following an ERCP, performed on 19 March 2020, in which she suffered an 
iatrogenic perforation to her oesophagus. The procedure should never have been performed 
on this date and in the circumstances as it was unsafe to do so when Anita’s capacity and 
consent had not been appropriately assessed, and her history of dysphagia had not been 
explored. 
Anita died as a direct result of the procedure which was performed as a result of significant 
failings in her care.” 

“Peter died on 8 November 2020, at the Queens Medical Centre, Nottingham, from multi-
organ failure caused by necrotising pancreatitis, which occurred as result of an ERCP 
procedure performed on 4 September 2020.  Pancreatitis is a recognised complication of this 
procedure, which was necessary in order to treat Peter’s symptomatic choledocholithiasis.” 

“Carol died on 11 September 2020, at the Queens Medical Centre, Nottingham, as a result of 
acute haemorrhagic pancreatitis, that was induced by an ERCP performed to treat 
choledocholithiasis, on 10 September 2020. Carol was at an elevated risk of developing this 
complication based on patient and procedure risk factors.” 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 4  CIRCUMSTANCES OF THE DEATH 

All four patients died from endoscopic retrograde cholangio-pancreatography related 
complications, within a 6-month period, caused by the same doctor, during his training for 
this high-risk procedure. 

5  CORONER’S CONCERNS 

During the course of the investigation my inquiries revealed matters giving rise to concern. In 
my opinion there is a risk that future deaths could occur unless action is taken.  In the 
circumstances it is my statutory duty to report to you. 

The MATTERS OF CONCERN are as follows:  

1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical 
indication for, and safety of, ERCP are identified in advance of the procedure and discussed 
with the patient. 
2. A lack of robust system for the recording of vetting of the procedure, capturing what 
information has been considered as part of this process. 
3. Consent is not personalised, contrary to recommendations made by the ESGE in December 
2019. 
4. A Lack of accountability between professionals for ensuring robust vetting and consent. 

6  ACTION SHOULD BE TAKEN 

In my opinion action should be taken to prevent future deaths and I believe you (and/or 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 February 17, 2022.  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 Chief Coroner and to the following Interested Persons      

Nottingham University Hospitals NHS Trust 
Dr 
The families of the Deceased 
Care Quality Commission 

I have also sent it to         

The British Society of Gastroenterology 
The Joint Advisory Group on GI Endoscopy 
The European Society of Gastrointestinal Endoscopy Guidelines Committee 

who may find it useful or of interest. 

I am also under a duty to send a copy of your response to the Chief Coroner and all 
interested persons who in my opinion should receive it. 

I may also send a copy of your response to any person who I believe may find it useful or of 
interest. 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 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 he believes may find it useful or of 
interest.   

You may make representations to me, the coroner, at the time of your response about the 
release or the publication of your response by the Chief Coroner. 

9 

 Dated: 23 December 2021 

Miss Laurinda Bower 
HM Assistant Coroner 

Regulation 28 – After Inquest 
Document Template Updated 30/07/2021

Responses

1 response published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.

Response from City Hospital Campus (PDF)
Please ask for the Medical Director’s Personal Assistant 

9 February 2022 

STRICTLY CONFIDENTIAL 
Miss Laurinda Bower 
HM Assistant Coroner for Nottingham City and Nottinghamshire 
HM Coroner’s Court 
The Council House 
Market Square 
Nottingham   NG1 2DT 

Dear Miss Bower 

Inquest: ERCP and Prevention of Future Death Notification 

Medical Director’s Office 
3rd Floor, Trust Headquarters 
City Hospital Campus 
Hucknall Road 
Nottingham 
NG5 1PB 

www.nuh.nhs.uk 

Please find attached a commentary that I have prepared in response to the Preventing Future Deaths 
Report  issued  to  Nottingham  University  Hospitals  NHS  Trust  following  the  inquest  into  four  patients 
who  died  following  endoscopic  retrograde  cholangio-pancreatography  related  complications,  within  a 
6-month period at the Trust.

I was not present at the inquest but note that there are four broad matters of concern identified in the 
PFD notification. 

My  response  to  each  of  the  concerns  identified  in  the  PFD  have  been  informed  following  work 
undertaken  by  colleagues  involved  in  the  Gastroenterology  Service,  the  Surgical  and  Medical 
Divisions  and  other  teams  and  individuals  in  the  organisation, including  the  Deputy  Medical  Director 
who is also the Chair of the Trust’s Consent Committee. 

The  actions  either  taken  or  planned  in  response  to  the  learning  from  the  inquest  are  summarised 
below.  The  oversight  of  the  delivery  of  these  actions  will  be  through  the  Surgical  Division’s 
Governance Committee. The Quality and Safety Oversight Group will be receiving reports on progress 
and the Quality Assurance Committee, a sub-committee of the Trust Board will be updated. 

I hope that this commentary provides assurance that we are committed to learning from this, and other 
incidents  to  significantly  enhance  the  care  of  patients  undergoing  ERCP  at  Nottingham  University 
Hospitals NHS Trust. 

Yours sincerely 

Dr 
Medical Director   

cc: 

, Inspections Manager, CQC    (

 
 
 
 
 
 
 Response to concerns identified through the PFD 

1.  A  lack  of  robust  patient  pathway  to  ensure  that  all  patient  factors  relevant  to  the  clinical 
indication  for,  and  safety  of,  ERCP  are  identified  in  advance  of  the  procedure  and  discussed 
with the patient.  

The following actions have been taken to address this concern: 

•  The  referral  pathway  has  been  completely  re-designed  and  will  move  away  from the  old  ‘NOTis’ 
based  information  system  to  Medway  orders  (the  current  information  system  in  use  in  the  Trust) 
from  14  February  2022.  The  Medway  order  will  incorporate:  information  on  the  indication,  latest 
blood  tests,  date  and  findings  of  relevant  imaging,  capacity  for  consent,  awareness  of  LPA, 
highlighting  potential  factors  for  “higher  risk”  procedures,  and  seek  history  or  symptoms  of 
dysphagia for any procedure with side-viewing endoscopes (ie EUS and ERCP). 

•  The Medway referrals will be  vetted daily by consultants who undertake ERCPs in dedicated job 

planned time.  

•  Outcomes  of  vetting  will  be  recorded  as  Medway  notes  (including  referrals  not  accepted)  and  if 
accepted  will  be  listed  for  procedures  (either  sedation  or  general  anaesthetic)  by  the  NUH 
endoscopy administration teams. 

•  The new fields on the NUH internal Medway orders will be replicated on the specific “NUH tertiary 
endoscopy referrals” form that are completed for referrals from outside NUH (eg from surrounding 
networking trusts) and will also be reviewed in the vetting clinics described above. 

•  Two new 2-hour clinics have been set up, that will run 52 weeks a year, staffed by consultants who 
undertake ERCPs.  These sessions have already commenced and permanent funding is currently 
being agreed. This clinic time will be used to meet, either virtually or in person, with all out-patients 
referred for ERCP to discuss the indications, risks and alternatives.  

•  We have already formally extended our post-ERCP recovery time to a  minimum of 2 hours, with 
clinical  review  and  if  any  significant  changes  to  baseline  observations  or  ongoing  symptoms  this 
period of observation is extended, or results in hospital admission for observation, investigations or 
treatment.  

2.  A  lack  of  robust  system  for  the  recording  of  vetting  of  the  procedure,  capturing  what    
information has been considered as part of this process.  

•  As above this will now be recorded through a clinical note on the Medway information system. This 

will be visible to all clinicians caring for the patient. 

3. Consent is not personalised, contrary to recommendations made by the ESGE in December 
2019. 

It is not currently possible for individual personalised risk to be calculated precisely although there are 
aspirations for this at some point in the future. It is possible to provide estimates of the relative risk to 
an individual patient in relation to the wider population risks and to ensure that this is documented in 
the patient record. A number of actions to support this have already commenced: 

•  Endoscopy outreach nurses will supply patient information booklets to ward in-patients but consent 
will  be  conducted  by  the  ERCP  endoscopist  on  in-patient  ward  reviews  before  attending  the 
endoscopy unit. 

•  Where  patients give  their  agreement, family  members  will  be  actively  sought  to  contribute  to the 

consent process.  

•  NUH  has  been  accepted  as  part  of  the  EIDO  pilot  study  of  home  consent.  This  will  include 
developing  a  video  explainer  similar  to  one  already  developed  at  NUH  relating  to  colonoscopy: 
https://www.youtube.com/watch?v=D42s37HXIoQ 

 
 
 
 
 
 
 
 
 
 •  Patient information and consent forms will be amended to include a statement that “I understand 
that you cannot give me a guarantee that particular person will perform the procedure. The person 
performing the procedure will have appropriate experience or expert supervision”. 

•  Consent forms will be amended to include the opportunity for clinicians to document enhanced risk 

where it is appropriate. 

•  Audit of the NUH ERCP practice over the last 3 years shows that pre-procedure administration of 
rectal  NSAIDs  (eg  diclofenac  100mg;  which  reduces  the  risk  of  post-ERCP  pancreatitis)  is 
consistently above 95%, in line with ESGE 2019 guidelines. 

•  A  cross-departmental  (HPB  endoscopy,  HPB  surgery  and  interventional  radiology)  meeting  with 
key stakeholders has been convened to design pathways for the best approach for complex HPB 
cases  (eg  endoscopic  versus  percutaneous  approaches  to  treating  complex  strictures  or  difficult 
bile ducts stones; combined laparoscopic cholecystectomy and laparoscopic bile duct exploration 
versus pre-operative ERCP then laparoscopic cholecystectomy) on 9 March 2022.  

4. A Lack of accountability between professionals for ensuring robust vetting and consent.   

• 

It is expected that the vetting and consent arrangements described above will resolve this issue. 

In addition to the above, we have developed our specialist HPB endoscopy team so that 5 out of 6 
(previously  3  out  of  6)  endoscopists  can  perform  lower-risk  diagnostic  EUS  and  only  proceed  if 
appropriate to ERCP (eg if any residual uncertainty regarding presence of bile duct stones) rather 
than having to delay treatment for repeat imaging or cancel procedures “on the day”. No other UK 
HPB endoscopy unit has this level of combined EUS/ERCP service provision. 

Summary 

The actions set out above are intended to address the matters of concern identified in the Preventing 
Future Deaths report in relation to:  

1.  A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication 
for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.  
2.  A  lack  of  robust  system  for  the  recording  of  vetting  of  the  procedure,  capturing  what  information 

has been considered as part of this process.  

3.  Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.  
4.  A Lack of accountability between professionals for ensuring robust vetting and consent.  

Some of these have already been implemented and dates have been provided for completion of the 
remainder.  As Medical Director, I will, via the Quality and Safety Oversight Group, ensure that these 
actions are monitored to completion.

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