Rhianne Barton

Coroner's concerns

AI summary

Lack of obstetric consultant supervision, failure to consider surgical causes despite bariatric history, and poor documentation of observations contributed to delayed diagnosis and care. National guidelines on bariatric surgery in pregnancy are also lacking.

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Rhianne's named obstetric consultant was not informed of her emergency admission. Although there was a consultant obstetrician on the ward on the 11lh February there was no request for Rhianne to be seen and in any event it was not common practice for patients to be seen by another consultant As such there was no obstetric consultant supervision of Rhianne from the time of admission until shortly before her surgery; approximately 43 hours after admission: No consideration was given to excluding surgical cause of Rhianne's symptoms despite the history of sudden onset of upper abdominal pain in knowledge that she had had bariatric surgery: heard evidence that bariatric surgery can, not infrequently , result in an omentallinternal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more_women are becoming_pregnant following_bariatric surgery RTdoc/00651-2015/Reg28 being the day delay the also heard evidence that whilst the rarity of an omental band may make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause; by undertaking appropriate investigations in a timely fashion: Evidence was presented of poor documentation of routine observations and an incomplete fluid balance chart, No accurate records were kept with regard to fluid intake and urine output It was not possible to assess the amount, frequency and volume of the vomitus: There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding: The obstetric consultant made no specific plans with regard to the obstetric care that Rhianne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery: also heard evidence that bariatric surgery was becoming increasingly common but the Royal College of Obstetrics and Gynaecology had not specifically addressed this in their guidance to practicing clinicians_

Responses

1 respondent

Ashford and St Peters Hospital NHS Trust NHS / Health Body

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Action Taken

The Trust has changed Consultant working practices to facilitate timely review of patients, produced a guideline for the management of pregnant women who have undergone bariatric surgery, raised awareness of documenting fluid balance, introduced training and competency assessments for staff, and is planning to introduce an electronic system for capture of patient observations. (AI summary)

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Dear Ms Church RE: Miss Rhianne Anoushka Florence BARTON (Deceased) Regulation 28 Report to Prevent Future Deaths In response to the Matters of Concern raised in Dr Henderson's Regulation 28 Report; Rhianne'$ named obstetric consultant was not informed of her emergency admission. Although there was a consultant obstetrician on the ward on the Ilth February there was no request for Rhianne to be seen and in any event it was not common practice for patients to be seen by another consultant. As such there was no obstetric consultant supervision of Rhianne from the time of admission until shortly before her surgery; approximately 43 hours after admission: We have actioned a change in Consultant working practices to facilitate timely review of patients on Joan Booker Ward: The default planning is that Consultants will review patients under their care working day; where other commitments or absences preclude this, and at weekends, the labour ward Consultant will review the patients_ This pattern of working has been in place since March 2015. have included as Appendix 1 the details of this working pattern: No consideration was given to excluding a surgical cause of Rhianne's symptoms despite the history of sudden onset of upper abdominal in the knowledge that she had had bariatric surgery Iheard evidence that bariatric surgery can, not infrequently, result in an omentallinternal hernia causing small bowel obstruction but that it was not widely understood and should be given greater recognition nationally as more women are becoming pregnant following bariatric surgery: The Division (Womens Health and Paediatrics) have produced a Guideline For The Management Of Pregnant Women Who Have Previously Undergone Bariatric Surgery which details the care pathway for this group of patients from booking of the pregnancy through to delivery. The document was ratified by the Divisional Governance Group in December 2015 and widely publicised to all stakeholders within the Trust_ A copy of this guideline is available on request Ia Saxa every pain

Ashford and St. Peter's Hospitals [E NPS Foundlation Irust The guideline will be reviewed and amended as required when the Royal College of Obstetrics and Gynaecology publish thier own guidance_ Ialso heard evidence that whilst the rarity of an omental band make it difficult to diagnose there was still a responsibility to exclude other causes of abdominal pain in the absence of an obstetric cause, by undertaking appropriate investigations in a timely fashion. Our Guideline For The Management Of Pregnant Women Who Have Previously Undergone Bariatric Surgery makes specific reference to the management of abdominal pain in patients who have had previous bariatric surgery and the need to exclude uncommon but serious complications of such surgery. The recent (June 2016) publication by the Royal College of Obstetrics and Gynaecology entitled The Management of Nausea and Vomiting of Pregnancy and Hyperemesis Gravidarum (Green-top Guideline No.69) gives guidance on the diagnosis and managment of Nausea and Vomiting of pregnancy and how to differentiate this from other causes of similar symptoms. Guidance from this publication will be incorporated into local Trust documents as appropriate. Evidence was presented ofpoor documentation of routine observations and an incomplete fluid balance chart. No accurate records were kept with regard to fluid intake and urine output. It was not possible to assess the amount, frequency and volume of the vomitus There was no evidence of diarrhoea despite a diagnosis of gastroenteritis. A urine dipstick was undertaken which revealed 4+ of glucose but no action was undertaken with regard to the finding: Audit of documentation of patient observations, including fluid balance, is part of a regular programme of audit of ward care In addition, a directed audit of documentation of fluid balance was undertaken in Joan Booker Ward in May 2015; this highlighted inconsistencies in chart completion with overall balance totals rarely calculated_ As a result; a campaign to raise awareness of the importance of correctly documenting fluid balance was undertaken and new training and compentancy assessments were introduced for staff who complete fluid balance charts. redesigned fluid balance chart has been developed to facilitate accurate and complete recording of input and output details. repeat; in depth, audit of fluid balance documentation will take place later this year following introduction and embedding of the new chart An electronic system (Vitalpac)for capture of patient observations has been introduced into the Trust in the majority of inpatient areas. The Division have approached the developer of this system to see if modifictions can be made to make it suitable for use in a maternity setting: This system can automatically calculate 'early warnig scores' and issue alerts based on predetermined criteria_ may

Ashford and St, Peter'$ Hospitals NHS NHS toundation Irust The obstetric consultant made no plans with regard to the obstetric care that Rhianne would receive during pregnancy and labour despite knowing that she had undergone bariatric surgery. Ialso heard evidence that the Royal College of Obstetrics and Gynaecology had not specifically addressed this issue in their guidance to practicing clinicians We note the intention of the Royal College of Obstetrics and Gynaecology to publish guidance relating to the care of patients with morbid obesity and following bariatric surgery: As referenced above, in December 2015 we introduced our own guidance for the managment of these patients throughout their pregnancy and labour: hope the details of the changes we have made to our practices are sufficient to allay the concerns you have raised in your report: Please do not hesitate to contact me should you require further details or documentation.

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Investigation and inquest

On 17h February 2015 commenced an investigation into the death of Rhianne Anoushka Florence BARTON_ 27 years of age_ The investigation concluded at the end of the inquest on March 16uh 2016. The medical cause of death given was: 1a. Acute respiratory distress syndrome and aspiration pneumonitis, small bowel infarction 1b. Gut obstruction (operation) Ic. Previous bariatric surgery My narrative conclusion was: Rhianne died from complications arising from the surgical management of small bowel obstruction in circumstances when the delay in investigation; diagnosis and management directly contributed to her death

Circumstances of the death

Rhianne Barton was a 27 year old women who underwent bariatric gastric bypass surgery in December 2013_ On the morning of the 10th February 2015 she developed a sudden onset of severe abdominal pain and vomiting when she was 35 weeks pregnant with her first child. This did not improve and she contacted the labour ward of St Peter's hospital Chertsey in the afternoon of the 10h February 2015 and attended there later on in the afternoon: Prior to this her antenatal course had been entirely uncomplicated and she was being considered for delivery in a low risk birthing unit: Rhianne was triaged on the labour ward by a midwife She was still complaining of severe unremitting upper abdominal pain with vomiting/retching_ There was a note made of diarrhoea but this was not seen during her time in hospital: Previous bariatric surgery was also noted and documented. She was reviewed by a specialist registrar in obstetrics later on that evening and a diagnosis of a self-limiting gastroenteritis was made (but not documented) for which analgesia and fluids were prescribed. No investigations were considered or undertaken nor was management plan documented During that night Rhianne continued to have severe upper abdominal pain and the midwife caring for her contacted the obstetric team who did not review Rhianne but prescribed intravenous rather than oral analgesia. Rhianne was next reviewed by a post fellowship obstetric trainee on the morning of the 11th February who noted her symptoms and considered this may be 'dumping syndrome' and requested a surgical review if there was no improvement: Rhianne did not improve and surgical review was requested at or around midday: During_the afternoon and evening Rhianne's mother_gave evidence that she was unhappy with the care that RTdoc/00651-2015/Reg28

Rhianne was receiving and was concerned about the level of pain and vomiting Rhianne was experiencing: This level of concern was not shared by the midwives who felt Rhianne was stable. Documentation with regard to routine observations was unclear and there was an incomplete fluid balance chart; It was not possible to assess the extent of Rhianne's fluid intake, vomiting (amount or consistency) or diarrhoea despite a diagnosis of gastroenteritis being made. Rhianne's mother felt her concerns were not addressed, Rhianne's mother had undergone bariatric surgery herself and gave evidence that she felt Rhianne was suffering from an 'internal hernia' as this is something she had also suffered post operatively: This evidence was disputed by the midwives and the surgical team. A further request was made for surgical review during the evening after concerns were raised by Rhianne's mother but the on call surgical registrar did not attend until midnight: When they did attend they did not find any indication for immediate surgery and documented that Rhianne would be reviewed again in the morning There was also disputed evidence with regard to that consultation; Rhianne was reviewed the following morning by surgical consultant who gave differential diagnosis of bowel obstruction from a mesenteric hernia or cholecystitis (bilirubin and amylase were however normal) and requested an ultrasound examination which was undertaken in the early afternoon. This showed ascites and dilated loops of bowel suggestive of small bowel obstruction: This was confirmed by MRI scan later on that afternoon. decision was made to undertake LSCS followed by surgical management of the bowel obstruction_ She was pre-assessed by anaesthetic team and prepared for surgery in the obstetric theatre_ On induction of anaesthesia Rhianne aspirated a considerable amount of bowel contents from a failed intubation as a result of a rapid sequence induction undertaken by a junior anaesthetic trainee in the presence of two supervising consultant anaesthetists. Rhianne suffered an iIll-defined period of hypoxia until her airway was secured by a successful intubation from one of the attending consultant anaesthetists Rhianne's baby daughter was delivered and surgical treatment of the bowel obstruction commenced. This was foreshortened by Rhianne becoming severely physiologically compromised with evidence of developing multi-organ failure: Despite maximal resuscitation and support she continued to deteriorate and whilst Rhianne was being prepared for ECMO she had an unresuscitable cardiac arrest and died in the early hours of the 13th February 2015. heard sufficient evidence that Rhianne should have been investigated and operated on the previous for relief of her bowel obstruction and if this had happened then she would not have aspirated and would not have died when she did, That the in receiving treatment directly caused her death: There was considerable discussion as to whether siting naso-gastric tube would have also altered the outcome but given the wide-ranging views heard in evidence for and against this procedure made no finding of fact on this matter:

Action should be taken

In my opinion action should be taken to prevent future deaths and believe you and your organisation: St Peter's Hospital, the Royal College of Obstetrics and Gynaecology, CQC and GMC have the power to take such action.

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