Elsie Woodfield
PFD Report
Historic (No Identified Response)
Ref: 2021-0211
Coroner's Concerns (AI summary)
Concerns include inconsistent consenting for endoscopy, failure to perform a 'sip test', a doctor not acting on a dangerous complication indicated in a report, and poor record-keeping by senior staff.
View full coroner's concerns
[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) There appears to be a significant discrepancy between clinicians on the consenting procedure for the identical treatment of endoscopy.
(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust.
(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication.
(4) Appropriate records were not kept, or were not properly transferred, by senior staff.
OFFICIAL
(2) A ‘sip test’ to exclude aspiration was not performed, and there has been no evidence that this had been noted or remedied at the Trust.
(3) A doctor did not take action when viewing an endoscopy report which contained an indication of a possible dangerous complication.
(4) Appropriate records were not kept, or were not properly transferred, by senior staff.
OFFICIAL
Sent To
- University Hospitals Plymouth NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
16 Aug 2021
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
Following an Inquest opened on the 19 December 2017 and an inquest hearing at HM Coroner's Court, Plymouth on the 7 June 2021 heard before Ian Michael Arrow, in the coroner's area for Plymouth, Torbay and South Devon.
Circumstances of the Death
The deceased suffered from significant comorbidities in particular ischaemic heart disease. She was determined by her GP to be suffering from Anaemia. She was admitted to hospital for a blood transfusion whilst in hospital, hospital clinicians determined an endoscopy was an appropriate procedure to investigate blood loss. This endoscopy investigation was carried out on 11th of December 2017. The endoscopy investigation was abandoned. On the balance of probability there was a perforation of the oesophagus during the procedure. The deceased developed symptoms of surgical emphysema. She deteriorated and died on 11th of December 2017 at Derriford Hospital, Plymouth.
NARRATIVE
NARRATIVE
Action Should Be Taken
Please review the matters of concern in para 5 above.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16 August 2021. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
YOUR RESPONSE
You are under a duty to respond to this report within 56 days of the date of this report, namely by Monday 16 August 2021. I, the coroner, may extend the period.
Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed.
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.