Source · Prevention of Future Deaths
Elsie Woodfield
Ref: 2021-0211
Date: 21 Jun 2021
Coroner: Ian Arrow
Area: Plymouth Torbay and South Devon
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner identified that a sip test to exclude aspiration was not performed and a doctor did not act on an endoscopy report indicating a dangerous complication. There were also concerns about discrepancies in consenting procedures for endoscopy and inadequate record keeping by senior staff.
Date
21 Jun 2021
56-day deadline
16 Aug 2021 est.
estimated from the report date
Responses identified
0 of 1
Coroner's concerns
The coroner identified that a sip test to exclude aspiration was not performed and a doctor did not act on an endoscopy report indicating a dangerous complication. There were also concerns about discrepancies in consenting procedures for endoscopy and inadequate record keeping by senior staff.
View full coroner's concerns
(1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy.
(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust.
(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication.
(4) Appropriate records were not kept, or were not properly transferred, by senior staff.
(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust.
(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication.
(4) Appropriate records were not kept, or were not properly transferred, by senior staff.
Report sections
Investigation and inquest
Following an Inquest opened on the 19 December 2017 and an inquest hearing at HM Coroner's Court, Plymouth on the 7 June 2021 heard before Ian Michael Arrow, in the coroner's area for Plymouth, Torbay and South Devon.
Circumstances of the death
The deceased suffered from significant comorbidities in particular ischaemic heart disease. She was determined by her GP to be suffering from Anaemia. She was admitted to hospital for a blood transfusion whilst in hospital, hospital clinicians determined an endoscopy was an appropriate procedure to investigate blood loss. This endoscopy investigation was carried out on 11th of December 2017. The endoscopy investigation was abandoned. On the balance of probability there was a perforation of the oesophagus during the procedure. The deceased developed symptoms of surgical emphysema. She deteriorated and died on 11th of December 2017 at Derriford Hospital, Plymouth.
NARRATIVE
NARRATIVE
Action should be taken
Please review the matters of concern in para 5 above.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16 August 2021. 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.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16 August 2021. 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.
Similar PFD reports
Report details
- Reference
- 2021-0211
- Date of report
- 21 June 2021
- Coroner
- Ian Arrow
- Coroner area
- Plymouth Torbay and South Devon
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: 16 Aug 2021 (estimated from the report date).
Sent to
- University Hospitals Plymouth NHS Trust