Allison had undergone elective Bariatric surgery in April 2017 . In October 2017 , she developed a chest infection and was reviewed in the Accident and Emergency Department of BRI and diagnosed with pneumonia and prescribed antibiotics_ Mary

Subsequently she was prescribed further antibiotics by her General Practitioner; her symptoms persisted and she was referred once again to BRI, following which she was discharged without further treatment or follow up. On 18th November she was admitted to BRI due to a worsening in her condition Following test and investigations she was diagnosed as suffering from gastro pulmonary fistula (a connection between the remaining part of her stomach her left lower lung) which had resulted in a very severe lung infection_ the evidence presented the development of such fistula rare but recognised complication of bariatric surgery. Allison was under the care of her original treating surgeon, he sought the assistance and input of visiting thoracic surgeon: A joint decision was taken by both doctors to treat the fistula with conservative treatment in the hope and expectation that the infection and fistula would resolve, and Allison remained in hospital until 14th December 2017_ Subsequent investigations revealed that although the fistula was reducing in size , persisted. Sometime in January 2018 a decision was taken between and that the fistula was unlikely to fully resolve without surgical intervention, and in addition a section of Allison's damaged left lung should also be removed. This required both their specialisms and decision was taken that both surgical interventions would be performed at the same time None of the treating clinicians giving evidence at the inquest could identify any record being made of this, within Allison's medical notes_ discussed his proposed part of the surgery with Allison in an outpatient appointment did not discuss his proposed surgery with Allison until he saw Allison in the theatre area immediately before Allison underwent surgery on Sth March 2018. Post operatively Allison spent an initial period in Intensive she was then transferred to ward 21 surgical ward, however her condition gave rise for concern and she was transferred back to intensive care for a further period until 11 March 2018. However on the morning of 12th March whilst on ward 21, Allison's vital signs began to deteriorate_ It was unclear from the evidence presented to me whether despite this deterioration Allison's vital signs were not more frequently checked in the next 24 hour period in accordance with hospital guidelines. Furthermore from the evidence presented to me it was unclear whether escalation measures to more senior clinicians were undertaken in the next 24 hour period by nursing staff in a timely manner once again in accordance with hospital guidelines_ What was clear from the evidence presented to me was that from approximately 11.0Oam the following 13th March there was significant escalation in Allison's care_ Following review by senior clinicians at this time, a decision was taken that Allison required emergency surgery_ Even before surgery commenced, Allison suffered cardiac arrest; which was successfully treated and From Care, day

Operative findings included pneumothorax and infective_pericarditis which were treated surgically. In addition treating surgeon undertook further surgical intervention in an effort to repair the underlying fistula at the site of Allison's remaining stomach_ Allison survived surgery, however her condition deteriorated post operatively and despite full intensive support she died on the 16"h March 2018.