University Hospitals of North Midlands
NHS / Health Body
Action Planned
The Trust has strengthened the information given to patients on discharge following ERCP, and a draft document with amended information is currently being ratified through the Trust's governance processes. The updated information highlights the importance of returning to hospital if vomiting or other symptoms start at home. (AI summary)
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Dear Mrs
2 The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at the inquest;, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family's confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged hospital: He advised that he would recommend that hospital review its pre and post procedure ERCP documentation provided to patients_ Action Taken Following the inquest; the Trust has reviewed matters raised by H M Assistant Coroner and the following response outlines the Trusts position Borgogno's case has been discussed with the ERCP team and staff who work in the department: The procedure information sheet advises that the post-procedure observations will be undertaken for hours and that patients will only be discharged once safe and with their agreement: Post ERCP_ all the patients have observations every 10 minutes for the first hour, and then 15 minutes, 30 minutes or hour until the time of discharge (4 after the procedure) depending on the patients clinical condition. If concerns are raised during the 4 hour observation period a clinician is asked to review the patient and the frequency of monitoring, the period of observation in recovery and time of discharge (same discharge or observation overnight in the hospital) is decided_ A single episode of vomiting with no other symptom will not automatically trigger an extended period of observation. 2_ The Trust has strengthened the information given to patients on discharge following ERCP . have attached the draft document for you with the amended information in red_ This is currently being ratified through the Trust'$ governance processes but it now highlights the importance of returning to hospital if vomiting, and other symptoms, start at home_ This is to cover those uncommon situations where symptoms develop post 4 hours following the ERCP procedure. sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mrs Gladys Borgogno seriously. The Trust strives to provide high standard of care to all patients and am grateful to you for raising these concerns on this occasion: Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours Ruu Tracy Bullock CHIEF EXECUTIVE Encs: Post procedure patient information leaflet 2 of 1 til from the Mrs every every hours the day Page
2 The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at the inquest;, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family's confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged hospital: He advised that he would recommend that hospital review its pre and post procedure ERCP documentation provided to patients_ Action Taken Following the inquest; the Trust has reviewed matters raised by H M Assistant Coroner and the following response outlines the Trusts position Borgogno's case has been discussed with the ERCP team and staff who work in the department: The procedure information sheet advises that the post-procedure observations will be undertaken for hours and that patients will only be discharged once safe and with their agreement: Post ERCP_ all the patients have observations every 10 minutes for the first hour, and then 15 minutes, 30 minutes or hour until the time of discharge (4 after the procedure) depending on the patients clinical condition. If concerns are raised during the 4 hour observation period a clinician is asked to review the patient and the frequency of monitoring, the period of observation in recovery and time of discharge (same discharge or observation overnight in the hospital) is decided_ A single episode of vomiting with no other symptom will not automatically trigger an extended period of observation. 2_ The Trust has strengthened the information given to patients on discharge following ERCP . have attached the draft document for you with the amended information in red_ This is currently being ratified through the Trust'$ governance processes but it now highlights the importance of returning to hospital if vomiting, and other symptoms, start at home_ This is to cover those uncommon situations where symptoms develop post 4 hours following the ERCP procedure. sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mrs Gladys Borgogno seriously. The Trust strives to provide high standard of care to all patients and am grateful to you for raising these concerns on this occasion: Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours Ruu Tracy Bullock CHIEF EXECUTIVE Encs: Post procedure patient information leaflet 2 of 1 til from the Mrs every every hours the day Page