Prevention of Future Deaths reports · 2023
Regulation 28 report to prevent future deaths, reference 2023-0355, written 29 Sep 2023. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 29 Sep 2023 |
|---|---|
| Reference | 2023-0355 |
| Deceased | Marion Luckraft |
| Coroner | Graeme Irvine |
| Coroner area | East 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.
MRG IRVINE
SENIOR CORONER
EAST LONDON
Walthamstow Coroner's Court, Queens Road Walthamstow, E17 SQP
REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1)
REGULATION 28 REPORT TO PREVENT FUTURE DEATHS
THIS REPORT IS BEING SENT TO:
1.
, Chief Executive Officer, Barking, Havering & Redbridge,
University Trust
1
CORONER
I am Graeme Irvine, senior coroner, for the coroner area of East London
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.
httQ :LLwww.legislation .gov.ukLukQgaL2009L25Lschedu1eLSLQaragraQhL7
httQ:LLwww.legislation .gov. ukL u ksiL2013L 1629LQa rtL7Lmade
3
INVESTIGATION and INQUEST
On 19th April 2023 I commenced an investigation into the death of Marion May Luckraft
aged 84. The investigation concluded at the end of the inquest on 11 th September 2023.
The conclusion of the inquest was a short-form conclusion of natural causes.
The medical cause of death was found to be;
1 a Shock due to biliary sepsis
1 b Retroperitoneal duodenal perforation following endoscopic retrograde
cholangiopancreatography (ERCP) and placement of pancreatic stent.
1c Biliary obstruction due to upper Qastrointestinal maliQnancv
4
CIRCUMSTANCES OF THE DEATH
Mrs Luckraft was admitted to hospital on 31/3/23 with jaundice.
Diagnostic tests suggested an obstructed biliary system, an ultrasound scan showed a
dilated common bile duct (CBD).
Further imaging occurred on 2/4, a CT abdomen with findings suggestive of CBD
stricture and possible malignancy. A MRCP (Magnetic Resonance
Cholangiopancreatography) provided a corroborative result on 4/4.
On 11/4 an ERCP (Endoscopic Retrograde Cholangiopancreatography) was
undertaken and an unsuccessful attempt to insert a stent into the CBD was undertaken.
A stent was inserted in the pancreatic duct.
A CT scan 13/4 on showed a duodenal perforation by displaced biliary stent with
retroperitoneal gas/fluid.
A number of factors; the patient's deterioration, an attempt at drainage through
interventional radiology, and discussion regarding which hospital site should be utilised,
led to delays in transferring the patient to another hospital for a laparotomy and washout
which occurred on 16/4.
The patient passed away on 17/4/23 on ITU.
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 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. Cumulative delays in the execution of diagnostic processes and treatments of
the patient probably increased the risk of Mrs Luckraft developing biliary sepsis.
2. Following the duodenal perforation suffered by the patient there was a failure to
promptly escalate her care to a high dependency unit despite her NEWS score
of 8.
3. The fragmentation of the patient's treatment across two sites of the Trust
contributed to delays in her treatment.
4 . The absence of a clear and workable treatment pathway fro biliary sepsis
contributed to delays.
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 b 13th November 2023. 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
2
I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons the fam ily of
. I have also sent it to the local Director of Public
Health 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 other person who I believe may find it
useful or of interest.
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.
9
[DATE] 29/09/2023
[SIGNED BY CORONER
3
See every Prevention of Future Deaths report matching Hospital Death (Clinical Procedures and medical management) related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.