Gladys Borgogno
PFD Report
All Responded
Ref: 2019-0286
All 1 response received
· Deadline: 13 Dec 2019
Coroner's Concerns (AI summary)
Post-procedure observation periods were insufficient after vomiting, and pre/post-procedure documentation failed to adequately advise patients on seeking medical attention for post-discharge vomiting.
View full coroner's concerns
(1) The length of the post procedure observation period where there has been an episode of vomiting in the absence of any other symptoms and normal observations (2) The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital: In evidence at inquest; the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family's confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged from hospital. He advised that he would recommend that the hospital review its pre and post procedure ERCP documentation provided to patients
Responses
Action Planned
The Trust has strengthened the information given to patients on discharge following ERCP, and a draft document with amended information is currently being ratified through the Trust's governance processes. The updated information highlights the importance of returning to hospital if vomiting or other symptoms start at home. (AI summary)
The Trust has strengthened the information given to patients on discharge following ERCP, and a draft document with amended information is currently being ratified through the Trust's governance processes. The updated information highlights the importance of returning to hospital if vomiting or other symptoms start at home. (AI summary)
View full response
Dear Mrs
2 The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at the inquest;, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family's confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged hospital: He advised that he would recommend that hospital review its pre and post procedure ERCP documentation provided to patients_ Action Taken Following the inquest; the Trust has reviewed matters raised by H M Assistant Coroner and the following response outlines the Trusts position Borgogno's case has been discussed with the ERCP team and staff who work in the department: The procedure information sheet advises that the post-procedure observations will be undertaken for hours and that patients will only be discharged once safe and with their agreement: Post ERCP_ all the patients have observations every 10 minutes for the first hour, and then 15 minutes, 30 minutes or hour until the time of discharge (4 after the procedure) depending on the patients clinical condition. If concerns are raised during the 4 hour observation period a clinician is asked to review the patient and the frequency of monitoring, the period of observation in recovery and time of discharge (same discharge or observation overnight in the hospital) is decided_ A single episode of vomiting with no other symptom will not automatically trigger an extended period of observation. 2_ The Trust has strengthened the information given to patients on discharge following ERCP . have attached the draft document for you with the amended information in red_ This is currently being ratified through the Trust'$ governance processes but it now highlights the importance of returning to hospital if vomiting, and other symptoms, start at home_ This is to cover those uncommon situations where symptoms develop post 4 hours following the ERCP procedure. sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mrs Gladys Borgogno seriously. The Trust strives to provide high standard of care to all patients and am grateful to you for raising these concerns on this occasion: Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours Ruu Tracy Bullock CHIEF EXECUTIVE Encs: Post procedure patient information leaflet 2 of 1 til from the Mrs every every hours the day Page
2 The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at the inquest;, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family's confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged hospital: He advised that he would recommend that hospital review its pre and post procedure ERCP documentation provided to patients_ Action Taken Following the inquest; the Trust has reviewed matters raised by H M Assistant Coroner and the following response outlines the Trusts position Borgogno's case has been discussed with the ERCP team and staff who work in the department: The procedure information sheet advises that the post-procedure observations will be undertaken for hours and that patients will only be discharged once safe and with their agreement: Post ERCP_ all the patients have observations every 10 minutes for the first hour, and then 15 minutes, 30 minutes or hour until the time of discharge (4 after the procedure) depending on the patients clinical condition. If concerns are raised during the 4 hour observation period a clinician is asked to review the patient and the frequency of monitoring, the period of observation in recovery and time of discharge (same discharge or observation overnight in the hospital) is decided_ A single episode of vomiting with no other symptom will not automatically trigger an extended period of observation. 2_ The Trust has strengthened the information given to patients on discharge following ERCP . have attached the draft document for you with the amended information in red_ This is currently being ratified through the Trust'$ governance processes but it now highlights the importance of returning to hospital if vomiting, and other symptoms, start at home_ This is to cover those uncommon situations where symptoms develop post 4 hours following the ERCP procedure. sincerely hope that this report provides the Coroner with assurance that the University Hospitals of North Midlands NHS Trust has taken the matters arising from the inquest touching upon the death of Mrs Gladys Borgogno seriously. The Trust strives to provide high standard of care to all patients and am grateful to you for raising these concerns on this occasion: Should you wish to discuss any aspect of this report further, please do not hesitate to contact me directly. Yours Ruu Tracy Bullock CHIEF EXECUTIVE Encs: Post procedure patient information leaflet 2 of 1 til from the Mrs every every hours the day Page
Sent To
- University Hospital of North Midlands
Response Status
Linked responses
1 of 1
56-Day Deadline
13 Dec 2019
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
On 3" may 2018 an investigation into the death of Gladys Margaret Borgogno was commenced: The investigation concluded at the end of the inquest on 29th July 2019. The conclusion of the inquest was that the deceased died due to a recognised complication of a surgical procedure The cause of death was: 1a Acute pancreatitis_ 1b Gallstones and endoscopic retrograde cholangiopancreatography (ERCP) Hypertensive heart disease:
Circumstances of the Death
1 JOn the 24th April 2018, Mrs Borgogno underwent an ERCP procedure due to symptomatic bile duct stones The procedure was uneventful but some stones remained Mrs Bogogno'$ post procedure observations were normal but prior to discharge, she was noted to vomit bile. This was not regarded as being indicative of a diagnosis of pancreatitis following a medical review as there were no other clinical symptoms
3) Mrs Borgogno was discharged home after the standard four hour post procedure hospital observations and provided with written discharge instructions which warned of seeking further medical advice if severe symptoms developed which included vomiting:
4) Mrs Borgogno continued to vomit in the car on the way home and at home; but did not seek further medical attention:
5) Mrs Borgogno was found the following morning lifeless on her living room floor with vomit in close proximity and was confirmed dead by paramedics at 1Oam on the 25th April 2018.
3) Mrs Borgogno was discharged home after the standard four hour post procedure hospital observations and provided with written discharge instructions which warned of seeking further medical advice if severe symptoms developed which included vomiting:
4) Mrs Borgogno continued to vomit in the car on the way home and at home; but did not seek further medical attention:
5) Mrs Borgogno was found the following morning lifeless on her living room floor with vomit in close proximity and was confirmed dead by paramedics at 1Oam on the 25th April 2018.
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you and your organisation have the power to take such action:
Copies Sent To
Trent & North Staffordshire You
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.