Source · Prevention of Future Deaths
Margaret Easterfield
Ref: 2014-0091
Date: 3 Mar 2014
Coroner: Rachel Redman
Area: Kent (South East & Central)
Responses identified: 0 / 1
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A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
Date
3 Mar 2014
56-day deadline
26 Apr 2014
Responses identified
0 of 1
Coroner's concerns
A rare anastomotic leak following surgery, leading to the patient's death, raises concerns about a potential technical error by the surgeon.
View full coroner's concerns
I am concerned that Mrs Easterfield underwent surgery on 26th October 2012 following which there was an anastomotic leak. She was discharged from hospital on the 30th October and was readmitted on 31st October, becoming profoundly unwell in the afternoon of the 3rd November and dying on the 4th November. I consider that a leak of ileo-ileal anastomosis is relatively rare and raises the question of technical error on the part of the surgeon. Because of my concern about the incidences of an anastomotic breakdown, I am raising this matter with you as I believe you can carry out action to prevent further death.
Report sections
Investigation and inquest
On 19th February 2014 I commenced an investigation into the death of Margaret Joy Easterfield. The investigation concluded at the end of the inquest on 19th February 2014. The conclusion of the inquest was that Margaret Joy Easterfield died as a result of the unintended consequence of necessary surgical treatment
Circumstances of the death
Margaret Joy Easterfield required a reversal of Ileostomy loop. She developed peritonitis after requiring readmission to hospital after the surgery and subsequently died there.
Action should be taken
To monitor incidences of an anastomotic breakdown within the Surgical Directorate at East Kent Hospitals NHS Trust.
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Report details
- Reference
- 2014-0091
- Date of report
- 3 March 2014
- Coroner
- Rachel Redman
- Coroner area
- Kent (South East & Central)
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: 26 Apr 2014.
Sent to
- East Kent University Hospital