Portsmouth Hospital NHS Trust
NHS / Health Body
Action Taken
The Trust has implemented a new Bariatric Discharge Protocol, incorporated into the bariatric pathway booklet, which requires a review by a bariatric team member or suitable clinician prior to discharge, with specific criteria that must be met. This protocol has been shared at surgical governance meetings, bariatric team meetings, and emailed to surgical staff, and will be added to nursing surgical study days and ward level safety huddles. (AI summary)
View full response
Dear Ms Olsen
Prevention of Future Deaths Report issued following the inquest into the death of Susan Evans held at the Portsmouth Coroner’s Court on 22nd November 2024
I write in response to the Prevention of Future Deaths (PFD) Report issued by HM Coroner following the conclusion of the inquest into the death of Susan Evans. In summary the coroner’s concerns, as expressed in the prevention of future deaths report are that, in contravention of the Trust’s post operative policy for patients who have undergone gastric bypass surgery, Susan Evans:
1. Was not seen by a bariatric specialist nurse, consultant or registrar on her final morning as an inpatient the morning she was discharged.
2. Was not reviewed by a senior doctor within 2 hours of increased abdominal pain in order to rule out anastomotic leak or bleed. And, in contravention of expected practice she:
3. Was not seen by a member of the specialist bariatric team prior to discharge. In response to the concerns set out above, there is already a policy in place which covers points 1 and 2. Unfortunately, on this occasion, it was sadly not followed. At least in part, because it was not clearly visible in the patient’s ward notes to act as a prompt. To counter this, the Bariatric lead surgeon has written a Bariatric Discharge Protocol (the new protocol) which has been incorporated into the bariatric pathway booklet which is completed for each patient undergoing bariatric surgery and kept in their medical notes for use by treating clinicians (doctors and nurses). This protocol requires a member of the bariatric team or suitable clinician to review the patient prior to discharge and ensure the patient’s pain is settling and controlled with suitable analgesia prior to discharge.
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986
This new protocol will also address point 3. The protocol sets out a list of 8 criteria which must be fulfilled before a post bariatric surgery patient is able to be discharged. This includes a daily review by a member of the bariatric team or senior member of the Upper GI surgical team. If their clinical condition does not fit with all listed criteria, they must not be discharged without direct discussion with a bariatric consultant surgeon. The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025. Additionally, the protocol has been emailed to all surgical staff working within general surgery who will have out of hours and emergency responsibility for bariatric patients. The new protocol will also be added to the nursing surgical study day and will be raised as part of the ward level safety huddles within surgery. I hope that the contents of this letter provide appropriate assurance that the concerns raised have been addressed.
Prevention of Future Deaths Report issued following the inquest into the death of Susan Evans held at the Portsmouth Coroner’s Court on 22nd November 2024
I write in response to the Prevention of Future Deaths (PFD) Report issued by HM Coroner following the conclusion of the inquest into the death of Susan Evans. In summary the coroner’s concerns, as expressed in the prevention of future deaths report are that, in contravention of the Trust’s post operative policy for patients who have undergone gastric bypass surgery, Susan Evans:
1. Was not seen by a bariatric specialist nurse, consultant or registrar on her final morning as an inpatient the morning she was discharged.
2. Was not reviewed by a senior doctor within 2 hours of increased abdominal pain in order to rule out anastomotic leak or bleed. And, in contravention of expected practice she:
3. Was not seen by a member of the specialist bariatric team prior to discharge. In response to the concerns set out above, there is already a policy in place which covers points 1 and 2. Unfortunately, on this occasion, it was sadly not followed. At least in part, because it was not clearly visible in the patient’s ward notes to act as a prompt. To counter this, the Bariatric lead surgeon has written a Bariatric Discharge Protocol (the new protocol) which has been incorporated into the bariatric pathway booklet which is completed for each patient undergoing bariatric surgery and kept in their medical notes for use by treating clinicians (doctors and nurses). This protocol requires a member of the bariatric team or suitable clinician to review the patient prior to discharge and ensure the patient’s pain is settling and controlled with suitable analgesia prior to discharge.
Portsmouth Hospitals University NHS Trust, Trust HQ, Queen Alexandra Hospital, Southwick Hill Road, Cosham, PO6 3LY Registered charity number: 1047986
This new protocol will also address point 3. The protocol sets out a list of 8 criteria which must be fulfilled before a post bariatric surgery patient is able to be discharged. This includes a daily review by a member of the bariatric team or senior member of the Upper GI surgical team. If their clinical condition does not fit with all listed criteria, they must not be discharged without direct discussion with a bariatric consultant surgeon. The new protocol, (which includes safety netting advice, advising patients how to make contact if they become unwell following discharge) has been shared at the Surgical Clinical Governance meeting which is attended by surgical resident doctors and consultants. The protocol was also discussed in the Bariatric Team meeting and is going to be discussed again at the Biannual AGM on 7/3/2025. Additionally, the protocol has been emailed to all surgical staff working within general surgery who will have out of hours and emergency responsibility for bariatric patients. The new protocol will also be added to the nursing surgical study day and will be raised as part of the ward level safety huddles within surgery. I hope that the contents of this letter provide appropriate assurance that the concerns raised have been addressed.