Source · Prevention of Future Deaths
Charles Woodward
Ref: 2016-0449
Date: 16 Dec 2016
Coroner: Nicholas Rheinberg
Area: Cheshire
Responses identified: 0 / 2
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Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
Date
16 Dec 2016
56-day deadline
13 Feb 2017
Responses identified
0 of 2
Coroner's concerns
Inadequate communication between the hospital, GP, and community nurses post-discharge, combined with insufficient patient monitoring and miscommunication with family, led to unappreciated health decline.
View full coroner's concerns
There was inadequate communication and liaison between the hospital on the one hand and on the other hand the deceased’s GP practice and district nurses in the community who, following the deceased’s discharge from hospital, would be responsible for the deceased’s ongoing care. Further, monitoring of the deceased’s condition from Leighton Hospital was insufficiently robust and relied upon oral contact rather than ensuring the physical presence of a medical attendant, be that attendant hospital or community based. The evidence suggested that there was miscommunication between the hospital and the deceased’s family with the result that the deceased’s worrying decline in health was not appreciated by the hospital.
Report sections
Investigation and inquest
On 3rd May 2016 an investigation was commenced into the death of Charles Ray Woodward aged 67. The investigation concluded at the end of the inquest on 15th December 2016. The conclusion of the inquest was that the deceased who had died as a result of peritonitis caused by virtue of a leaking anastomosis following surgery for cancer of the sigmoid colon had died by misadventure.
Circumstances of the death
On 20th April 2016 an operation was performed at Leighton Hospital, Crewe to remove a tumour involving the sigmoid colon. After an apparently uneventful period of recovery the deceased was discharged home from hospital on 22nd April 2016. At home the deceased’s health declined. He ate and drank little, he became oliguric, his mobility decreased and it is likely that he had begun to suffer from the peritonitis which subsequently led to his death. Further it is likely that had the deceased remained in hospital the onset of peritonitis would have been recognised and an operation performed which might have saved him.
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Report details
- Reference
- 2016-0449
- Date of report
- 16 December 2016
- Coroner
- Nicholas Rheinberg
- Coroner area
- Cheshire
Responses identified
Responses identified
0 of 2
2 responses not yet linked
Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 13 Feb 2017.
Sent to
- Cancer Governance Board
- Mid Cheshire NHS Trust