Sylvia Mitchell
PFD Report
All Responded
Ref: 2018-0383
Community health care and emergency services related deaths
Hospital Death (Clinical Procedures and medical management) related deaths
All 3 responses received
· Deadline: 7 Jul 2019
Coroner's Concerns (AI summary)
Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.
View full coroner's concerns
1. Evidence emerged during the inquest that there was inadequate communication between the Trust and GP advising Mrs Mitchell of the risks of not having the pessary removed urgently.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
2. Specifically, the Pathologist gave evidence confirming that pessaries are typically used in the non-surgical management of severe pelvic organ prolapse, often in post-menopausal women with poorly oestrogenised, and easily traumatised vaginal mucosa. A pessary is a foreign object in constant contact with the vaginal epithelium, therefore, its use requires adequate follow-up to ensure proper fitting, routine cleansing and monitoring of the integrity of the vagina. Failure to observe these precautions heightens risk of infection, impaction/incarceration and ulceration, potentially with recto-vaginal and/or vesico-vaginal fistulation – the latter are very rare iatrogenic complications of pessary use with only approximately 8 cases reported in the world literature (Gordon GH et al. J Clin Gynecol Obstet. 2015; 4 (1): 193-196), almost exclusively, however, associated with Gellhorn and shelf pattern prostheses, usually in the age range of 70 to 80 years, often allegedly contributed to by lapse of regular maintenance & hygiene procedures.
3. Due to the delays in removal of the pessary she died as a result of developing a fistula and urosepsis.
Responses
Action Taken
Every person attending for pessary insertion now receives an information leaflet. Processes have been amended to tighten follow up, including letters and offering a further appointment if there is no response. Patients who have missed follow-ups are being recalled for review. (AI summary)
Every person attending for pessary insertion now receives an information leaflet. Processes have been amended to tighten follow up, including letters and offering a further appointment if there is no response. Patients who have missed follow-ups are being recalled for review. (AI summary)
View full response
Dear Mr Siddique RE: Regulation 28 Report – Sylvia Mitchell I am in receipt of your Regulation 28 Report following the Inquest and your ruling on 27 November 2018, in respect of the late Mrs Sylvia Mitchell. It has taken too long to then reply to you, but we have in truth been working on this issue in the intervening time, and debating the implications with clinical colleagues including GP leaders. Your finding clearly has implications for all disciplines. In respect of Mrs Mitchell, I do believe that we attempted to review her at appropriate intervals and listed her for surgery to remove the pessary. Unfortunately she was unwell and unable to attend on the date organised and we requested that both the patient and the GP let us know when she was well enough to undergo surgery. As you know, this did not occur. We apply NHS- standard protocols for the ‘chasing’ of patients in these circumstances. Every person attending for pessary insertion now receives an information leaflet which clearly outlines the need for follow up appointments and the risks of having a pessary, including ulceration, bleeding and discharge. These are being translated into multiple languages. We will share these leaflets with primary care colleagues for provision in consult rooms locally. In addition, we had already amended our processes to tighten further our follow up procedure. Women self-book their 6 monthly appointments via partial booking, but if this does not happen we follow up with a letter. For women who do not attend for a planned appointment, we send a further appointment for 4 weeks’ time. This is repeated should they fail to attend again and then will write to the GP requesting them to review and let us know if a further appointment is required. We have now asked our Planned Care Board to undertake a twice yearly clinical review of any patient who does not reply to all of those efforts. This list, pseudo-anonymised, will also be provided to Primary Care Network colleagues. In other words we will be more overtly curious about the reasons for non-response. As part of this, looking forward patients who we have identified have not had a follow up as planned are being recalled for a review appointment with our Clinical Nurse Specialists. We are also discussing ways to enable us to easily see which women need follow up, and when this need
ceases, either because the pessary has fallen out, is no longer required for personal or alternative treatment reasons. You asked us to ensure that any patients who may have missed opportunities to be seen, as Mrs Mitchell was, are safe and this is in progress and will likely continue through this year. I am satisfied that we have a process in place which is recalling women appropriately and that we are developing further ways to identify those women who need following up in our service, rather than with their GP, to give a further safety net. In six months’ time we will review at the Trust’s Board data on non-responders within gynaecology services for the prior 18 months to see if there are any further omissions we might consider. My colleague, , Deputy Director of Governance, would be best placed to provide advice or further details on our actions, or indeed updates on the progress moving forward.
ceases, either because the pessary has fallen out, is no longer required for personal or alternative treatment reasons. You asked us to ensure that any patients who may have missed opportunities to be seen, as Mrs Mitchell was, are safe and this is in progress and will likely continue through this year. I am satisfied that we have a process in place which is recalling women appropriately and that we are developing further ways to identify those women who need following up in our service, rather than with their GP, to give a further safety net. In six months’ time we will review at the Trust’s Board data on non-responders within gynaecology services for the prior 18 months to see if there are any further omissions we might consider. My colleague, , Deputy Director of Governance, would be best placed to provide advice or further details on our actions, or indeed updates on the progress moving forward.
Noted
The GP provides a summary of the patient's medical history and care, noting cancelled appointments and home visits. (AI summary)
The GP provides a summary of the patient's medical history and care, noting cancelled appointments and home visits. (AI summary)
View full response
Dear Sirs D.O.B.: 02 March 1928 Re: I am , senior partner at the Oaks Medical Practice. I have been a GP for the past 28 years and have the following qualifications: Bachelor of Medicine, Bachelor of Surgery (Leicester University 1984) Member of the Royal College of General Practitioners: (Edinburgh 1989) Diploma of the Royal College of Obstetricians and Gynaecologists Diploma of Community Child Health Diploma of Palliative Medicine I am writing on behalf of the practice as left the Practice on 1st May 2017. was a patient of the practice registered with us from 13th December 1966. She was on the following regular medication: Cavilon Durable barrier cream (3M Health Care Ltd) 2 gram - use as directed Adcal-D3 Dissolve 1500mg/400unit effervescent tablets (Kyowa Kirin Ltd) 28 tablet - take one daily Aendronic acid 70mg tablets 4 tablet - take one weekly Administrative Notes: As per discharge summary 17.11.17 Aspirin 75mg dispersible tablets 28 tablet - take one daily Macrogol compound oral powder sachets NPF sugar free 1 20 sachet - 2 sachets twice a day Administrative Notes: Ad per discharge summary 17.11.17 Paracetamol 500mg tablets 224 tablet - take 2 tablets four times a day Senna 7.5mg tablets 56 tablet - take 2 at night Amoxicillin 250mg capsules 28 capsule - 1 EVERY DAY Splenectomy NEC (78403) Gaviscon Advance Mint chewable tablets (Reckitt Benckiser Healthcare (UK) Ltd) 28 tablet
- ASD, Mint Fortisip Compact liquid strawberry (Nutricia Ltd) 15000 ml - 1 twice daily
I have known since 12th April 1991. 1 was the last Doctor to have visited prior to her unfortunate death. Over the years she has become increasingly frail and became bedbound by 6th October 2017. When I saw her at home with her son present with a swelling of her left elbow. This was investigated with blood tests which were found to be acceptable and was treated with Naproxen and Omeprazole (this was stopped on 17th October 2017 following a telephone call as her elbow was better). Last contact was with her son on 22nd March 201 8 in order to continue her nutritional support. On looking at her records 1 . was called by City Hospital for removal of her pessary in December 2013 but this was cancelled by the patient as she was not feeling well. Following this (who also left the Practice on 1st November 2017) carried out a telephone call with her son and noticed that the ring pessary had not been changed since 2013, a referral was carried out on that day and an appointment was made on 1st August 2016. We have had no further correspondence regarding this referral.
2. She was seen on 13th February 2017 by (currently on leave, returning on 25th September 2018 ) who carried out a home visit with her son present, as carer’s had noticed a pessary coming out. He noted that she has a pessary for vaginal prolapse, on examination the abdomen was soft non-tender and inspection of vulva and introitus - no vaginal prolapse seen, no pessary seen. had a discussion with son and agreed as he cannot see a pessary coming out today or a vaginal prolapse, to wait and see. Advice was given to the son that if carer’s notice the pessary again, to contact us to refer to Gynaecology.
3. Looking through the records her last admission prior to 21 May 2018 was 29th October 2017 for Urosepsis secondary to “L”ureteric calculus, further investigation was not deemed possible due to patient frailty.
4. There were no further assessments by the GPs at the Practice.
5. There was an assessment for nutritional support on 30th November 2017. I believe the contents of this statement are true and to the best of my knowledge. It is with great sadness that the practice heard of her untimely death and I would like to convey our deepest sympathy at this sad time on behalf of the Oaks Medical Practice. I had dealt closely with and her son for many years and developed what I thought was a strong Patient - G.P. relationship.
- ASD, Mint Fortisip Compact liquid strawberry (Nutricia Ltd) 15000 ml - 1 twice daily
I have known since 12th April 1991. 1 was the last Doctor to have visited prior to her unfortunate death. Over the years she has become increasingly frail and became bedbound by 6th October 2017. When I saw her at home with her son present with a swelling of her left elbow. This was investigated with blood tests which were found to be acceptable and was treated with Naproxen and Omeprazole (this was stopped on 17th October 2017 following a telephone call as her elbow was better). Last contact was with her son on 22nd March 201 8 in order to continue her nutritional support. On looking at her records 1 . was called by City Hospital for removal of her pessary in December 2013 but this was cancelled by the patient as she was not feeling well. Following this (who also left the Practice on 1st November 2017) carried out a telephone call with her son and noticed that the ring pessary had not been changed since 2013, a referral was carried out on that day and an appointment was made on 1st August 2016. We have had no further correspondence regarding this referral.
2. She was seen on 13th February 2017 by (currently on leave, returning on 25th September 2018 ) who carried out a home visit with her son present, as carer’s had noticed a pessary coming out. He noted that she has a pessary for vaginal prolapse, on examination the abdomen was soft non-tender and inspection of vulva and introitus - no vaginal prolapse seen, no pessary seen. had a discussion with son and agreed as he cannot see a pessary coming out today or a vaginal prolapse, to wait and see. Advice was given to the son that if carer’s notice the pessary again, to contact us to refer to Gynaecology.
3. Looking through the records her last admission prior to 21 May 2018 was 29th October 2017 for Urosepsis secondary to “L”ureteric calculus, further investigation was not deemed possible due to patient frailty.
4. There were no further assessments by the GPs at the Practice.
5. There was an assessment for nutritional support on 30th November 2017. I believe the contents of this statement are true and to the best of my knowledge. It is with great sadness that the practice heard of her untimely death and I would like to convey our deepest sympathy at this sad time on behalf of the Oaks Medical Practice. I had dealt closely with and her son for many years and developed what I thought was a strong Patient - G.P. relationship.
Noted
The hospital acknowledges the patient cancelled her appointment and asks the GP to inform them when she is ready to reschedule. (AI summary)
The hospital acknowledges the patient cancelled her appointment and asks the GP to inform them when she is ready to reschedule. (AI summary)
View full response
Dear Dr Naik } ,i Re: Ms Sylvia Mitchell DOB: 02 Mar 1928 NHS Number: 488 827 9446 (01) 129 DUNEDIN ROAD GREAT BARR BIRMINGHAM B44 9DL il The above named lady has been sent 2 appointments to come in to hospital to have her ring pessary removed. However, she cancelled her last appointment with me as she did not feel well enough to come in I ,, I would be grateful if you could let me know when Sylvia feels ready to come in to hospital for her procedure and I would be more than happy to send her a new date. Consultant in Obstetrics & Gynaecology it J Please do not call the medical secretaries for test results as this information can not be given over the telephone ir- — ■ - -- Private & Confidential Copy to: Ms Sylvia Mitchell 129 DUNEDIN ROAD GREAT BARR B44 9DL A University of Birmingham Teaching Hospital CWZ34601 MITCHELL, Sylvia (Ms), printed 04 Mar 2026 12:54 (page 1 of 1)
Oaks Medical Centre 1 99 Shady Lane 1 1 9 Chester Road Great Barr Streetly Birmingham Sutton Coldfield B44 9ER B74 2HE FAX: 0121366 6977
Please send all correspondence to Shady Lane address 01 Jul 2016 Ms Sylvia Mitchell 129 Dunedin Road Great Barr Birmingham B44 9DL Dear Ms Mitchell Further to your recent consultation with , please find attached choose and book Appointment Details. An appointment has been booked for you as per Section 2 on the form. If you wish to change this appointment please follow the instructions in Section 3. Your password can be found on the back page. Many thanks.
Oaks Medical Centre 1 99 Shady Lane 1 1 9 Chester Road Great Barr Streetly Birmingham Sutton Coldfield B44 9ER B74 2HE FAX: 0121366 6977
Please send all correspondence to Shady Lane address 01 Jul 2016 Ms Sylvia Mitchell 129 Dunedin Road Great Barr Birmingham B44 9DL Dear Ms Mitchell Further to your recent consultation with , please find attached choose and book Appointment Details. An appointment has been booked for you as per Section 2 on the form. If you wish to change this appointment please follow the instructions in Section 3. Your password can be found on the back page. Many thanks.
Sent To
- Oaks Medical Centre
- Sandwell and West Birmingham NHS Trust
Response Status
Linked responses
3 of 2
56-Day Deadline
7 Jul 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 the 5 June 2018, I commenced an investigation into the death of Mrs Sylvia Mitchell. The investigation concluded at the end of the inquest on 27 November 2018. The conclusion of the inquest was a narrative conclusion of:
Died after developing a rare but recognised complication of urosepsis after failures to adequately monitor and review a patient with a shelf pessary which had become impacted and resulted in a recto-vagino-vesical fistula. These failures to review more than minimally, negligibly or trivially contributed to the death and neglect as rider is added to this narrative conclusion.
The cause of death was:
1a Urosepsis b Recto-Vagino-Vesical Fistula(impacted Gellhorn Pessary) c
II Chronic Degenerative Mitral & Aortic Valvar Disease. Nephrolithiasia
Died after developing a rare but recognised complication of urosepsis after failures to adequately monitor and review a patient with a shelf pessary which had become impacted and resulted in a recto-vagino-vesical fistula. These failures to review more than minimally, negligibly or trivially contributed to the death and neglect as rider is added to this narrative conclusion.
The cause of death was:
1a Urosepsis b Recto-Vagino-Vesical Fistula(impacted Gellhorn Pessary) c
II Chronic Degenerative Mitral & Aortic Valvar Disease. Nephrolithiasia
Circumstances of the Death
i) Mrs Mitchell was a 90 year old woman with a previous medical history of osteoarthritis and also bladder prolapse. She was managed conservatively for the latter condition initially with a ring pessary between December 1999 and Aril 2008. During this period the pessary was regularly changed. ii) From April 2008 onwards a new replacement Gelhorn pessary was issued. This was then reviewed in June but she failed to attend her appointment in September and did not then re-attend gynaecology services until 6 March 2013 when her GP referred her back. iii) She then attended the outpatient clinic and an impacted shelf pessary was found. This required a surgical procedure under anaesthetic to be removed. iv) She was then booked in for a pre-operative assessment but developed
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Action Should Be Taken
1. The Trust may wish to consider urgently reviewing the patients who maybe in a similar position and have failed to have any follow up review of the Gellhorn Pessary.
2. The GP Practice may wish to consider adding all patients to their list of patients with a pessary (either ring or Gellhorn) to ensure that adequate referral to gynaecology services occurs.
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3. To assist the Trust, I have attached a similar PFD report and the responses/audit performed by another Trust within the Black Country area.
2. The GP Practice may wish to consider adding all patients to their list of patients with a pessary (either ring or Gellhorn) to ensure that adequate referral to gynaecology services occurs.
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3. To assist the Trust, I have attached a similar PFD report and the responses/audit performed by another Trust within the Black Country area.
Similar PFD Reports
Reports sharing organisations, categories, or themes
Related Inquiry Recommendations
Public inquiry recommendations addressing similar themes
Responsibility for monitoring delivery of standards and quality
Mid Staffs Inquiry
GP oversight of specialist care
Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.