Samantha Shillito

Date: 1 March 2024 

Mr Kevin McLoughlin 
HM Senior Coroner 
West Yorkshire (Eastern District) 
HM Coroner’s Service 
71 Northgate 
Wakefield 
WF1 3BS 

Dear Mr McLoughlin 

Chief Medical Officer 
Trust Headquarters and 
Education Centre 
Pinderfields Hospital 
Aberford Road 
Wakefield 
WF1 4DG 

Executive Support Officer:  

Re: 

Inquest of Samantha Jade SHILLITO (dcd) – 28.04.1983 to 27.02.2022 – 1488090 – 
Case No. 28621 

I am responding on behalf of Mid Yorkshire Teaching NHS Trust (MYTT; the Trust) to the 
Regulation 28 Report to Prevent Future Deaths that you issued to the Trust and the Royal College 
of Radiologists on 1st December 2023, upon conclusion of the above inquest. 

The Matters of Concern raised in your report were: 

1)  There were no relevant specialist consultants in the hospital on the night of Friday 25/2/22, 
during Saturday 26/2/22 or on Sunday 27/2/22. Ms Shillito had a NEWS score which would 
have triggered an escalation of her treatment, but she was neither reviewed, examined properly 
or subjected to further investigations (such as blood tests and/or a CT scan) to establish the 
cause of her deterioration. Evidence was heard at the inquest from a consultant hepatologist to 
the effect that this was a missed opportunity to initiate remedial action when her deterioration 
could have been halted and her condition improved. 

2)  The ascitic tap procedure was said to be commonly undertaken and was regarded as low risk. 
The inquest was, however, unable to establish the magnitude of the risks of bleeding, infection 
or perforation of surrounding structures by reference to the medical literature or statistical 
evidence. How then can it be said to be a low-risk procedure if the inherent risks have not been 
quantified? This was viewed as a national (if not international) problem, which requires 
published evidence to inform radiological practice. 

3)  The practice at the hospital was to obtain verbal consent to the procedure from the patient in 
the minutes before it took place. A consultant radiologist acknowledged that the risk of death 
was not mentioned to Ms Shillito. It is questionable whether this can be considered to be a 
patient’s informed consent when the risks outlined are not reliably established, are not 
explained and the patient is not asked to sign a document. If there is a risk of death, 
irrespective of its rarity, the patient is entitled to be informed. This concern is highlighted when 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 one considers the patient’s medical condition and their likely emotional state, in circumstances 
which allow no time for reflection or discussion with other family members. It appears that no 
leaflet describing the ascitic tap procedure and the associated risks has been provided either 
by the Royal College of Radiologists or the hospital.  

4)  Ms Shillito’s family were not made aware of the seriousness of her underlying illness. No 
effective communication was provided to them even on Sunday 27 February to help them 
appreciate the gravity of her situation. Her husband and her mother informed the inquest that 
they had not been told that she might die. In consequence, the shock of her death on the 
evening of Sunday 27 February 2022 was all greater. It acknowledged that this concern did not 
contribute to Ms Shillito’s death, but it underlines the need for compassion and candour when 
dealing with patients and their families. 

I would like to thank you for bringing these matters to MYTT’s attention and for the additional time 
you’ve granted the Trust to provide its formal response.  We have carefully considered and 
discussed the concerns you’ve raised and their implications for the Trust.  Following a review of 
our processes, we will implement a number of measured actions in response as outlined below.   

Weekend coverage by Consultants and responding to deteriorating NEWS 

Specialist consultants are always available to be contacted out of hours and weekends if needed 
to provide advice and support for other clinical staff or to return directly to the hospital within a 
short time period if required.   At any given time there are therefore varying numbers of specialists 
within the hospital grounds. Across specialties a minimum of 25 Consultants are present during 
weekends. Some specialities do have a fixed onsite 24/7 presence during and others provide an 
on call service with expectations of a direct return to site if needed within a maximum of 30 
minutes.   

The Trust also has escalation protocols in place to recognise when a patient’s condition 
deteriorates, with appropriate response pathways prescribed.  However, we know these protocols 
require regular review to be assured they are fit for purpose and are continually improved locally, 
and across the NHS. We undertake ongoing education with our teams of nursing, allied health 
professions (AHP) staff, and junior doctors so that when deterioration of patients occur, they 
promptly receive correct specialist input and treatment.   

In addition we have recently introduced the Deteriorating Adult Response Team (DART) previously 
called the Critical Care Outreach Team (CCOT) as a 24/7 service. This multi professional team 
provides an initial response when patients with deteriorating NEWS are identified.  Guidance for 
referral includes a NEWS of 7 or more, an increasing oxygen requirement of above 40%, or if there 
are any concerns about a patient deteriorating (irrespective of their NEWS / oxygen requirement). 

We have augmented this service and also launched the Call 4 Concern patient safety initiative 
(based on Martha’s rule). This enables a patient or family member to seek help or advice if a 
patient’s condition deteriorates. A new phone number is publicised on wards which connects to 
members of DART for a response. Patients and family members can call for help or advice if: 

• 
• 

they see a noticeable change or deterioration in the patient’s clinical condition 
they feel a healthcare team has not recognised or responded appropriately to this 
deterioration. 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 When DART receives a Call 4 Concern the team will review the patient’s notes, observations and 
NEWS2 scores on PPM+.  They will then advise the ward team and/or directly support ongoing 
management of the patient’s care.  

Quantifying the risks of ascitic tap procedure 

As an organisation that provides healthcare, we rely on various sources of information to enable us 
to quantify the risks of any procedure. The majority of this information is sourced from guidance 
issued by specialist societies, royal colleges, or developed through literature evidence base/local 
audits etc. In the instance where there is an absence of specific quantifiable risks, best practice is 
to inform patients of potential complications with indicative likelihoods of these occurring. For an 
ascitic tap it is felt to be very low risk based on the experience and judgement of the health 
professionals involved. Decisions to proceed with an intervention would also be balanced against 
the risk of not proceeding with an intervention 

At the inquest you specifically noted that the Trust did not, and indeed could not, provide definitive 
advice to Ms Shillito quantifying the magnitude of the risks of bleeding, infection or perforation of 
the surrounding structure, in relation to the ascitic tap procedure.  You also noted that this was a 
national (if not international) problem, requiring published evidence to inform radiological practice.   

Therefore to address this concern fully, we welcome any advice from the Royal College of 
Radiologists (also issued with this regulation 28).  In the interim, however, we continue to work 
with our clinical teams to support appropriate risk/benefit assessments by the healthcare 
professional and consideration of these risks/benefits with patients prior to a procedure.   

Consenting for ascitic tap procedure  

As you are aware, the process of consenting a patient for a procedure is an ongoing one that 
starts with a conversation with the patient about treatment options and culminates with the signing 
of the consent form. The form itself is merely the final “ok” from the patient to go ahead after a 
number of steps have taken place over a length of time, to obtain fully informed consent from the 
patient.  

All treatment/interventional options ranging from the most benign non-invasive option such as a 
prescription for antibiotics or a blood test, to a highly invasive procedure, require informed consent 
from a patient before commencement, whether that consent is implied, verbal or written.  It is 
generally accepted that the greater the impact of a known risk occurring, the more important fully 
informed and documented consent is obtained from the patient.  Arguably the risk of death, no 
matter how remote, exists with almost every treatment and many diagnostic interventions offered.  
However, it would not be practicable for written consent to be obtained in every instance and, for 
many treatment options, verbal consent is deemed acceptable clinical practice. 

With regard to patient information leaflets, we do use patient information leaflets for many 
procedures but not universally for those procedures that are perceived to be very low risk. I 
acknowledge that in my own exploration of this concern I have identified several NHS Trusts which 
have information leaflets for a diagnostic ascitic tap procedure (needle removal of a small amount 
of fluid) and/or the more invasive paracentesis (usually implied as insertion of a drain to remove 
larger volumes of fluid). None of those leaflets specifically mention the risk of death. We will, 
however, review our patient safety leaflets in accordance with relevant guidance from professional 
bodies such as the Royal College of Radiologists and British Society of Interventional Radiology to 

 
  
 
 
 
 
 
 
 
 
 
 
 
 
  
 ensure we are supporting patients with the most contemporary medical advice to help make best 
informed shared decisions about their care.  

Communication with families  

I fully recognise the requirement for compassion and candour with patients and families as part of 
their medical care experience. I am sorry that our communications with Ms Shillito’s family fell 
below the high standard we strive to achieve, and that they were entitled to expect.  The Trust has 
wholeheartedly embraced the NHS's changed methodology for investigating patient incidents / 
events through the new national Patient Safety Incident Response Framework (PSIRF), where 
patients and families have a greater voice and involvement.  Aligned with this philosophy, the Trust 
is actively promoting a more compassionate and inclusive approach by staff/clinicians in all 
communications with patients and their families. We continue to work with our healthcare 
professional team members to embed this change in order to ensure appropriate communication 
with patients and their families regarding the care they receive occurs.  

In closing, I acknowledge that your concerns arose out of your investigation into the death of Ms 
Shillito, and on behalf of Mid Yorkshire Teaching NHS Trust, I would like to take this opportunity to 
offer our sincere condolences once again to Ms Shillito’s family in relation to her death and the 
impact this has had on them. 

Yours sincerely 

Chief Medical Officer

Senior Coroner Kevin McLoughlin 
The Coroner’s Courts 
Burgage Square 
Wakefield 
WF1 2TS 

7 November 2025  

Dear Mr McLoughlin, 

RCR Response to Regulation 28: Prevention of Future Deaths report issued on 1 
December 2023 in relation to the death of Samantha Jade Shillito. 

I was very sorry to read about the death of Samantha Jade Shillito, and I would like to 
express my deepest condolences to Samantha’s family.  

The Royal College of Radiologists (RCR) take the matters raised in your report very seriously 
and I hope this reply will be helpful in outlining how we are committed to learning from them 
and supporting our members and Fellows to develop and maintain excellent medical care.  

I sincerely apologise for the delay in sending this response. I can confirm that we have put 
additional measures in place to refine our process when responding to important 
correspondence such as your report.  

The RCR is a charity which works with our members and Fellows to improve medical care 
across the specialties of Clinical Radiology and Clinical Oncology. We promote excellence in 
professional practice within our specialties, and we produce a range of publications, including 
standards for the delivery of high-quality radiology services. 

In preparing this response, we sought input from our specialty interest groups most closely 
aligned with this area of practice, the British Society of Gastrointestinal and Abdominal 
Radiology (BSGAR) and the British Society of Interventional Radiology (BSIR) to ensure that 
our comments reflect the breadth of relevant expertise within the specialty. Their feedback 
has been incorporated into the general observations set out below. 

We note that points 1 and 4 in the matters of concern section of your report are not directly 
relevant to the remit or responsibilities of the RCR. Accordingly, our response focuses on 
matters 2 and 3. 

Risks associated with ascitic tap procedures 

Ascitic drainage is a frequently performed and generally low-risk procedure. Nevertheless, as 
the inquest notes, it carries recognised though uncommon risks including bleeding, infection 
and visceral perforation.  

 
 
 
 
 
 
 
 
 The British Society of Gastroenterology’s 2021 “Guidelines on the management of ascites in 
cirrhosis” are a comprehensive UK reference for this procedure and there are a number of 
other relevant references including: 

1.  De Gottardi A, Thévenot T, Spahr L, Morard I, Bresson-Hadni S, Torres F, Giostra E, 
Hadengue A. Risk of complications after abdominal paracentesis in cirrhotic patients: 
a prospective study. Clin Gastroenterol Hepatol. 2009 
https://doi.org/10.1016/j.cgh.2009.05.004 

2.  Kaveh Sharzehi, Vishal Jain, Ammara Naveed, Ian Schreibman. Hemorrhagic 

Complications of Paracentesis: A Systematic Review of the 
Literature.  Gastroenterology Research and Practice  2014 
https://doi.org/10.1155/2014/985141  

3.  Sparks HD, Sue MJ, Saab S, Kim-Saechao S, Lybbert S, Wong J, Lee 

EW.  Incidence and risks of complication following 2,230 image-guided abdominal 
paracentesis.  2025  Int J Gastrointest Intervention 
https://doi.org/10.18528/ijgii250002 

Our specialist interest groups emphasised that the risks of ascitic tap are well established 
and widely understood in current radiological practice. The use of ultrasound guidance has 
become standard and has been shown to further reduce complication rates. We therefore 
believe that the magnitude and nature of these risks are well defined in the published 
evidence base and are adequately reflected in existing national guidance. 

Consent and patient information 

The RCR archived its previous document Standards for patient consent particular to 
radiology (Second edition) in 2021, following the publication of the General Medical Council’s 
(GMC) updated guidance on decision making and consent. We fully endorse the GMC’s 
framework, which provides comprehensive and up-to-date principles for obtaining valid 
informed consent across all areas of medical practice, including radiology. 

Both BSGAR and BSIR have confirmed that they do not produce a specific patient 
information leaflet for ascitic drainage and the RCR does not produce patient information 
leaflets for individual procedures. This reflects our role as a professional body that sets and 
promotes standards of practice, rather than as a direct provider of patient-facing materials. 
However, BSIR has noted that the Cardiovascular and Interventional Radiological Society of 
Europe provides a general leaflet on fluid and abscess drainage procedures, which includes 
information on bleeding risks. BSIR also notes that there are numerous high-quality leaflets 
freely available through NHS trusts and related professional organisations. These typically 
include clear, evidence-based descriptions of procedure risks and are suitable for adaptation 
or local use. 

These leaflets typically do not specifically mention the risk of death although would be 
expected to be used as a supplement to an appropriate discussion with a patient where, in 
line with the GMC guidance, the information that the patient may wish to know should be 
explored.  

 
 
 
 
 
 
 I am grateful to you for bringing these matters of concern to our attention and for giving us 
the opportunity to respond. Once again, I express my deepest condolences to Ms Shillito’s 
family and loved ones. 

Yours sincerely, 

RCR President