Source · Prevention of Future Deaths
Ann Bennett
Ref: 2014-0233
Date: 9 May 2014
Coroner: David Hincliff
Area: West Yorkshire (East)
Responses identified: 0 / 1
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The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
Date
9 May 2014
56-day deadline
4 Jul 2014
Responses identified
0 of 1
Coroner's concerns
The coroner endorsed findings from a Trust investigation report that identified serious issues contributing to a potentially avoidable death, necessitating a robust response.
View full coroner's concerns
_ biliary act 1a)
71! am entirely satisfied with the findings of the Trust Level 2 Investigation Report 02961 prepared Consultant Physician dated March 2014 and the recommendations contained therein (2) Notwithstanding the above regard this as a potentially avoidable death and therefore wish to endorse those recommendations but must incorporate them in this report to ensure that the Trust has due regard to the seriousness of these issues and in order to elicit their response in accordance with this report and Regulation 28, save and accept those issues which were changed by events in respect of the Foundation Year One Doctor who is referred to as in the report:
71! am entirely satisfied with the findings of the Trust Level 2 Investigation Report 02961 prepared Consultant Physician dated March 2014 and the recommendations contained therein (2) Notwithstanding the above regard this as a potentially avoidable death and therefore wish to endorse those recommendations but must incorporate them in this report to ensure that the Trust has due regard to the seriousness of these issues and in order to elicit their response in accordance with this report and Regulation 28, save and accept those issues which were changed by events in respect of the Foundation Year One Doctor who is referred to as in the report:
Report sections
Investigation and inquest
On 26 April 2012 commenced an investigation into the death of Ann Bennett, age 61 The investigation concluded at the end of the Inquest on 22 April 2014. The conclusion of the Inquest was a
Circumstances of the death
Ann Bennett was a married lady aged 61 who had suffered with colic for six to eight months and was under the care of Professor Peter Lodge, Consultant Surgeon and Honorary Professor of Surgery at St James s University Hospital and was seen by him in his clinic at Wharfedale Hospital on Monday 16 April 2012 arising from which she was admitted for an emergency laparoscopic cholecystectomy which was carried out 18 April 2012 which resulted in a perforated bowel; poor post-operative care with a failure to upon important obvious symptoms and clear deteriorating observations which meant that a serious post-operative complication was not detected quickly. Mrs Bennett's death was confirmed on the Intensive Care Unit at St James's University Hospital, Leeds at 1220 hours on 20 April 2012. A post mortem examination shows the cause of the death to be Multi organ failure due to b) Septic shock due to c) Peritonitis due to small bowel perforation complicating laparoscopic cholecystectomy for gallstones
Action should be taken
In my opinion action should be taken to prevent future deaths and believe you AND your organisation have the power to take such action:
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Report details
- Reference
- 2014-0233
- Date of report
- 9 May 2014
- Coroner
- David Hincliff
- Coroner area
- West Yorkshire (East)
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: 4 Jul 2014.
Sent to
- Leeds Teaching Hospitals NHS Trust