Source · Prevention of Future Deaths

Barbara Rawlinson

Ref: 2023-0413Deceased Date: 1 Dec 2015 Coroner: Richard Brittain Area: Inner North London Responses identified: 0 / 1 View PDF

Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.

Date 1 Dec 2015
56-day deadline 1 Jan 2024 est.
Responses identified 0 of 1
Hospital Death (Clinical Procedures and medical management) related deaths

Coroner's concerns

AI summary
Pre-hysterectomy CT scans are not routinely performed, relying solely on ultrasound. This raises concern that uterine sarcoma diagnoses could be missed due to inadequate diagnostic imaging protocols.
View full coroner's concerns
(1) The lack of CT scanning prior to hysterectomy, with reliance only on ultrasonography, raises the concern that the diagnosis of uterine sarcoma could be missed in the future and consideration should be given as to whether steps can be taken to address this risk.

Report sections

Investigation and inquest
Barbara Rawlinson died on 16 July 2015, aged 58 years, from complications arising from a diagnosis of uterine sarcoma. An inquest into her death was heard on 11 November 2015, at which I recorded a narrative conclusion (see attached).
Circumstances of the death
Mrs Rawlinson presented to her GP in 2014 with post-menopausal bleeding and was referred to the gynaecology team at Barnet Hospital (part of the Royal Free Trust). She underwent ultrasound examinations and hysteroscopies to investigate the cause of this bleeding, which was presumed to be resulting from a fibroid. She was concerned that the diagnosis was cancerous and, in order to reassure her that this was not the case, she underwent a hysterectomy in early 2015. Unfortunately histology of her uterus demonstrated that the cause of the bleeding was a uterine sarcoma. She was referred to UCLH to receive further treatment of this cancer and underwent a further procedure to remove additional tumour mass which had been demonstrated on CT scanning. Unfortunately, following this procedure she developed a perforated stomach and subsequently a perforated gallbladder. She died after attempts to treat these and further complications. Mrs Rawlinson’s family raised a concern that no CT scanning had been undertaken prior to the hysterectomy being performed. Mr Broadbent, Consultant Gynaecologist at Barnet Hospital, had been appraised of this concern in writing before the inquest and had provided a supplementary written statement to address this. He set out that he had been reassured by the findings of repeated ultrasound scanning. As such, I did not call him to give evidence. However, at the inquest I heard from , Consultant Gynaecologist at UCLH who had undertaken Mrs Rawlinson’s second operation. She set out that, in her opinion, a CT scan should have been undertaken prior to the hysterectomy to address the possible (but rare) diagnosis of sarcoma in a post-menopausal woman with ongoing bleeding.

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Report details

Reference
2023-0413Deceased
Date of report
1 December 2015
Coroner
Richard Brittain
Coroner area
Inner North London

Responses identified

Responses identified 0 of 1
1 response not yet linked

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 1 Jan 2024 (estimated).

Sent to

Royal Free London NHS Foundation Trust

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