Source · Prevention of Future Deaths
Riaz Begum
Ref: 2018-0041
Date: 26 Jan 2018
Coroner: Anna Morris
Area: Manchester (South)
0 responses identified · 1 indexed addressee
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AI-generated concerns summaryThe coroner was concerned by a delay in a necessary CT-guided fluid drainage procedure due to insufficient staff and inadequate escalation. There were also no ERCP procedures available for six days due to a consultant's annual leave, causing further delays.
Date
26 Jan 2018
56-day deadline
2 Aug 2018 est.
estimated from the Judiciary.uk publication date
Responses identified
0 of 1
Coroner's concerns
The coroner was concerned by a delay in a necessary CT-guided fluid drainage procedure due to insufficient staff and inadequate escalation. There were also no ERCP procedures available for six days due to a consultant's annual leave, causing further delays.
View full coroner's concerns
_ Mrs: The Begum and
(1) am concerned that on the 3r 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary; it was not done until the 5th July 2017. The evidence have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure: (2) am also concerned that after the 3r July the need for the drainage to take place was not adequately escalated to Radiology management when indicated he could not undertake the procedure within the timescale requested When the matter was escalated on the 5"h July had to be essentially told to do the procedure and offered an additional professional fee consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone treated for sepsis and possible bile leak puts patients at risk. (3) am further concerned by the evidence 0 that after took annual leave on the 3r there were no further lists for ERCP procedures until his return on the 11th Whilst there mav have been other surgical consultants available to review Mrs: whilst he was on leave, his evidence was that once a bile leak was confirmed the ERCP should have taken place and this on his account would not have been possible for 6 days after the leak was diagnosed. found that this delay played a part in the development of acute pancreatitis in Mrs. Begum ad am concerned that any other caused by annual leave taken may cause further delays for ERCP' $ for a patient which creates a risk of future deaths_ ActIon SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you The Chief Executive of Tameside General Hospital NHS Trust have the power to take such action:
(1) am concerned that on the 3r 2017, a CT Scan indicated the need for fluid drainage to take place under CT guidance. Despite this procedure being deemed necessary; it was not done until the 5th July 2017. The evidence have heard causes me concern that there were insufficient radiologists/ radiological nurses available to carry out the procedure: (2) am also concerned that after the 3r July the need for the drainage to take place was not adequately escalated to Radiology management when indicated he could not undertake the procedure within the timescale requested When the matter was escalated on the 5"h July had to be essentially told to do the procedure and offered an additional professional fee consider that the lack of availability of suitable capacity for undertaking a drainage procedure in the case of someone treated for sepsis and possible bile leak puts patients at risk. (3) am further concerned by the evidence 0 that after took annual leave on the 3r there were no further lists for ERCP procedures until his return on the 11th Whilst there mav have been other surgical consultants available to review Mrs: whilst he was on leave, his evidence was that once a bile leak was confirmed the ERCP should have taken place and this on his account would not have been possible for 6 days after the leak was diagnosed. found that this delay played a part in the development of acute pancreatitis in Mrs. Begum ad am concerned that any other caused by annual leave taken may cause further delays for ERCP' $ for a patient which creates a risk of future deaths_ ActIon SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and believe you The Chief Executive of Tameside General Hospital NHS Trust have the power to take such action:
Report sections
Investigation and inquest
On 25/07/2017 commenced an investigation into the death of Riaz Begum: The investigation concluded at the end of the inquest 26th January 2018_ conclusion of the inquest was that Mrs underwent a routine laparoscopic cholecystectomy procedure at Tameside General Hospital on Z1st June 2017, a5 a complication of which she developed a bile leak: She was readmitted to Tameside General Hospital on 26th June 2017 on referral from her GP diagnosed with sepsis. A bile Ieak was diagnosed after drainage under CT guidance on Sth July 2017 produced bile-stained fluid: Mrs Begum underwent an ERCP to repair the bile leak on 13th July 2017 and developed acute pancreatitis a5 a complication of that procedure: The severity of that pancreatitis was exacerbated by the pre-existing sepsis and by a delay in diagnosing and repairing the bile leak: Mrs Begum'$ condition deteriorated and despite treatment for sepsis and multi organ failure she died on 16th July 2017. The medical cause of death was; 1a) Multi-organ failure 1 b) Acute pancreatitis 1 c) Biliary peritonitis 1 d) Recent cholecystectomy and ERCP
Circumstances of the death
See above
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Report details
- Reference
- 2018-0041
- Date of report
- 26 January 2018
- Coroner
- Anna Morris
- Coroner area
- Manchester (South)
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: 2 Aug 2018 (estimated from the Judiciary.uk publication date).
Sent to
- Tameside General Hospital NHS Trust