UK Inquiry Tracker

William Doleman, Anita Burkey, Peter Sellars and Carol Cole

PFD Report All Responded Ref: 2021-0432

Date of Report 23 December 2021

Coroner Laurinder Bower

Coroner Area Nottingham City and Nottinghamshire

Response Deadline est. 17 February 2022

Hospital Death (Clinical Procedures and medical management) related deaths

Judiciary.uk Report PDF

All 1 response received · Deadline: 17 Feb 2022

Coroner's Concerns (AI summary)

There was a lack of robust patient pathways, inadequate vetting, and non-personalised consent for ERCP procedures, coupled with insufficient accountability among professionals.

View full coroner's concerns

1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.
2. A lack of robust system for the recording of vetting of the procedure, capturing what information has been considered as part of this process.
3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.
4. A Lack of accountability between professionals for ensuring robust vetting and consent.

Responses

City Hospital Campus NHS / Health Body

9 Feb 2022

Action Planned
The hospital has taken or planned actions to improve ERCP patient pathways, vetting, consent, and accountability, including a specialist HPB endoscopy team and a meeting to design pathways for complex HPB cases scheduled for March 9, 2022. (AI summary)

View full response

Dear Miss Bower Inquest: ERCP and Prevention of Future Death Notification Please find attached a commentary that I have prepared in response to the Preventing Future Deaths Report issued to Nottingham University Hospitals NHS Trust following the inquest into four patients who died following endoscopic retrograde cholangio-pancreatography related complications, within a 6-month period at the Trust. I was not present at the inquest but note that there are four broad matters of concern identified in the PFD notification. My response to each of the concerns identified in the PFD have been informed following work undertaken by colleagues involved in the Gastroenterology Service, the Surgical and Medical Divisions and other teams and individuals in the organisation, including the Deputy Medical Director who is also the Chair of the Trust’s Consent Committee. The actions either taken or planned in response to the learning from the inquest are summarised below. The oversight of the delivery of these actions will be through the Surgical Division’s Governance Committee. The Quality and Safety Oversight Group will be receiving reports on progress and the Quality Assurance Committee, a sub-committee of the Trust Board will be updated. I hope that this commentary provides assurance that we are committed to learning from this, and other incidents to significantly enhance the care of patients undergoing ERCP at Nottingham University Hospitals NHS Trust.

Sent To

Nottingham University Hospitals NHS Trust

Response Status

Linked responses 1 of 1

56-Day Deadline 17 Feb 2022

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

Report Sections

Investigation and Inquest

I commenced investigations into the deaths of William DOLEMAN, Anita BURKEY, Peter SELLARS and Carol Christine COLE. The investigation concluded at the end of the inquests, heard together, between 15 November 2021 and 17 December 2021. The conclusion of the inquests were as follows: “Bill died on 1 April 2020, at the Queens Medical Centre, Nottingham, as a result of medical complications following an ERCP procedure performed on 19 March 2020, in which he suffered a recognised complication, namely a perforation to his duodenum, likely caused as a result of catheter trauma. At the time, the procedure was not clinically indicated, and ought not to have gone ahead. If the procedure had been postponed for further imaging, Bill would not likely have died when he did and in the manner that he did. Failures in his pre-procedure care directly contributed to his death. There were missed opportunities to have diagnosed and treated Bill’s perforation during the procedure, and while this would likely have reduced his risk of dying, it might not have prevented his death.” “Anita died on 5 April 2020, at the City Hospital, Nottingham, as a result of medical complications following an ERCP, performed on 19 March 2020, in which she suffered an iatrogenic perforation to her oesophagus. The procedure should never have been performed on this date and in the circumstances as it was unsafe to do so when Anita’s capacity and consent had not been appropriately assessed, and her history of dysphagia had not been explored. Anita died as a direct result of the procedure which was performed as a result of significant failings in her care.” “Peter died on 8 November 2020, at the Queens Medical Centre, Nottingham, from multi-organ failure caused by necrotising pancreatitis, which occurred as result of an ERCP procedure performed on 4 September 2020. Pancreatitis is a recognised complication of this procedure, which was necessary in order to treat Peter’s symptomatic choledocholithiasis.” “Carol died on 11 September 2020, at the Queens Medical Centre, Nottingham, as a result of acute haemorrhagic pancreatitis, that was induced by an ERCP performed to treat choledocholithiasis, on 10 September 2020. Carol was at an elevated risk of developing this complication based on patient and procedure risk factors.”

Circumstances of the Death

All four patients died from endoscopic retrograde cholangio-pancreatography related complications, within a 6-month period, caused by the same doctor, during his training for this high-risk procedure.

Copies Sent To

Nottingham University Hospitals NHS Trust Dr British Society of Gastroenterology The Joint Advisory Group on GI Endoscopy The European Society of Gastrointestinal Endoscopy Guidelines Committee

Inquest Conclusion

“Bill died on 1 April 2020, at the Queens Medical Centre, Nottingham, as a result of medical complications following an ERCP procedure performed on 19 March 2020, in which he suffered a recognised complication, namely a perforation to his duodenum, likely caused as a result of catheter trauma. At the time, the procedure was not clinically indicated, and ought not to have gone ahead. If the procedure had been postponed for further imaging, Bill would not likely have died when he did and in the manner that he did. Failures in his pre-procedure care directly contributed to his death. There were missed opportunities to have diagnosed and treated Bill’s perforation during the procedure, and while this would likely have reduced his risk of dying, it might not have prevented his death.” “Anita died on 5 April 2020, at the City Hospital, Nottingham, as a result of medical complications following an ERCP, performed on 19 March 2020, in which she suffered an iatrogenic perforation to her oesophagus. The procedure should never have been performed on this date and in the circumstances as it was unsafe to do so when Anita’s capacity and consent had not been appropriately assessed, and her history of dysphagia had not been explored. Anita died as a direct result of the procedure which was performed as a result of significant failings in her care.” “Peter died on 8 November 2020, at the Queens Medical Centre, Nottingham, from multi-organ failure caused by necrotising pancreatitis, which occurred as result of an ERCP procedure performed on 4 September 2020. Pancreatitis is a recognised complication of this procedure, which was necessary in order to treat Peter’s symptomatic choledocholithiasis.” “Carol died on 11 September 2020, at the Queens Medical Centre, Nottingham, as a result of acute haemorrhagic pancreatitis, that was induced by an ERCP performed to treat choledocholithiasis, on 10 September 2020. Carol was at an elevated risk of developing this complication based on patient and procedure risk factors.”