On 19th April 2023 I commenced an investigation into the death of Marion May Luckraft aged 84. The investigation concluded at the end of the inquest on 11th September 2023. The conclusion of the inquest was a short-form conclusion of natural causes. The medical cause of death was found to be; 1 a Shock due to biliary sepsis 1 b Retroperitoneal duodenal perforation following endoscopic retrograde cholangiopancreatography (ERCP) and placement of pancreatic stent. 1c Biliary obstruction due to upper Qastrointestinal maliQnancv

Mrs Luckraft was admitted to hospital on 31/3/23 with jaundice. Diagnostic tests suggested an obstructed biliary system, an ultrasound scan showed a dilated common bile duct (CBD). Further imaging occurred on 2/4, a CT abdomen with findings suggestive of CBD stricture and possible malignancy. A MRCP (Magnetic Resonance Cholangiopancreatography) provided a corroborative result on 4/4. On 11/4 an ERCP (Endoscopic Retrograde Cholangiopancreatography) was undertaken and an unsuccessful attempt to insert a stent into the CBD was undertaken. A stent was inserted in the pancreatic duct. A CT scan 13/4 on showed a duodenal perforation by displaced biliary stent with retroperitoneal gas/fluid. A number of factors; the patient's deterioration, an attempt at drainage through interventional radiology, and discussion regarding which hospital site should be utilised, led to delays in transferring the patient to another hospital for a laparotomy and washout which occurred on 16/4. The patient passed away on 17/4/23 on ITU.