UK Inquiry Tracker

Christopher MacMorland

PFD Report All Responded Ref: 2016-0415

Date of Report 16 November 2016

Coroner David Horsley

Coroner Area Portsmouth and South East Hampshire

Response Deadline ✓ from report 11 January 2017

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 11 Jan 2017

Sent To

Portsmouth Hospitals NHS Trust

Response Status

Responses 1 of 1

56-Day Deadline 11 Jan 2017

All responses received

About PFD responses

Organisations named in PFD reports must respond within 56 days explaining what actions they are taking.

Source: Courts and Tribunals Judiciary

Coroner's Concerns

was told in evidence at the Inquest that despite Mr MacMorland being under the care of consultant gastroenterologists during his final admission to hospital he was at no time treated in a specialist gastroenterology ward even though the consultants had during that time requested such a transfer on five separate occasions. Given the nature of his medical problems, from the evidence heard, am of the opinion that he could have benefitted from the expertise and facilities available in a gastroenterology ward which might have had an effect on the outcome_ was also told that it is common for consultants' requests for patient transfer to specialist wards not to be implemented.

Responses

Portsmouth Hospitals NHS Trust

20 Dec 2016

Response received

View full response

Dear Mr Horsley Regulation 28 letter Re: Christopher MacMorland DOB 13.10.51 Inquest date: November 2016 The Regulation 28 letter refers to the care of this patient which was provided by both an Upper Gastrointestinal (UGI) Surgeon and a Gastroenterologist: Your concerns related to the failure to transfer the patient to a Gastroenterology ward as requested by the Gastroenterologist The patient had had a surgical procedure in the previous month and hence was on the specialist UGI surgical ward and was admitted under the care of the UGI Surgeon: The staff on the Gastrointestinal Surgical ward would have been familiar with medical gastrointestinal disorders and thus we do not believe care was in any way compromised. By way of further assurance, since this death in 2015, the Hospital has begun 'buddy' ward system whereby patients of certain specialty are cohorted only into the appropriate specialist ward Or specific buddy ward This means that consultants will have their patients only on one other ward if their own base ward is full, trust this provides you with appropriate reassurance_

Action Should Be Taken

In my opinion action should be taken to prevent future deaths and believe your organisation have the power to take such action.

Report Sections

Investigation and Inquest

On 22nd July 2016 | commenced an investigation into the death of Christopher Allen MacMORLAND (D.O.B. 13/10/1951). The investigation concluded at the end of the inquest on November 2016. The conclusion of the inquest was: Medical cause of death: la: Multiple Organ Failure Ib: Sepsis Ic: Spontaneous Bacterial Peritonitis and Pelvic Abscess Il: Myocarditis, Cardiac Hypertrophy, Chronic Obstructive Pulmonary Disease and Oesophagectomy for Carcinoma of the Oesophagus 2012_ Coroner's Conclusion as to the death: Death due to Natural Causes_

Circumstances of the Death

Mr MacMorland was admitted to Queen Alexandra Hospital between 14th and 20th October 2015 having had difficulty feeding: feeding tube was inserted and he returned home_ He was readmitted to the hospital on 10th November 2015 with abdominal pain and distension, feeling generally unwell. Despite treatment, his condition deteriorated and he died at the hospital on 5" December 2015.