On the 18 December 2017, I commenced an investigation into the death of Mrs Margaret Spencer. The investigation concluded at the end of the inquest on 22 March 2018. The conclusion of the inquest was a short narrative conclusion of:

Died after developing complications arising from a failure to remove a pessary that had been put in place in 2014. A failure to do a timely follow up review due to system failures in IT and administrative input errors contributed to a decline in her condition and these failures and omissions were contributed to by neglect.

The cause of death was:

1a Acute Kidney Injury b Hospital Acquired Pneumonia c ll Ischaemic Heart Disease, Frailty, Forgotten Vaginal Pessary

i) Mrs Spencer was under the care of the Manor Hospital Gynaecology clinic at Manor Hospital. She had regular appointments and review after being diagnosed with a prolapse. This was treated with a pessary. ii) She last saw and was reviewed by her Consultant on the 23 May 2014 and a new pessary given. iii) Due to a change in IT systems no follow up review took place and her condition deteriorated with her reporting frequent urinary tract infections during 2017. iv) This resulted in further hospital admissions and in November 2017 it was discovered that the pessary had eroded through the bladder. v) Sadly despite plans for further surgery her condition continued to decline and she passed away on the 17 December 2017 after developing

[IL1: PROTECT] pneumonia and acute kidney injury.

1. You may wish to consider further reviewing the systems in place to ensure that all relevant patients identified during the relevant period have been identified and further treatment offered as needed. In addition you may wish to review that this IT system change did not result in any other patients across the Trust having their cases closed prematurely.