Helen Turner
PFD Report
Historic (No Identified Response)
Ref: 2016-0159
Coroner's Concerns (AI summary)
Critical delays in diagnosing a sigmoid colon obstruction and subsequently performing stenting and surgery led to a severe deterioration in the patient's condition. These delays significantly reduced her chances of survival.
View full coroner's concerns
During_the course of the inquest the evidence revealed matters giving_rise to concern In my Elphicks Farmhouse, Hunton, Kent; MEIS OSB Tel 01622 820412 Fax 01622 820800 The delay opinion there is a risk that future deaths will occur unless action is taken: _ There was a delay in confirming the diagnosis of sigmoid colon obstruction which did not take place until 12.04.15, some four days after her admission to William Harvey Hospital: There was a in the decision for Mrs Turner to undergo a stenting of four days, by which time her condition had deteriorated thus rendering her unsuitable for this procedure. There was a delay in operating on Mrs Turner to remove the bowel obstruction which did not take place until 20.04.15 by which stage her condition had deteriorated to a critical level: The expert evidence heard at the Inquest found that Mrs Turner had a 90% chance of surviving the diagnosis of cancer and abdominal surgery to remove the tumour: Because of the delay in diagnosis and surgery, her chances of survival were diminished
Sent To
- East Kent Hospitals University NHS Foundation Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
9 Jun 2016
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 21/05/2015 commenced an investigation into the death of Helen Jennifer Turner. investigation concluded at the end of the Inquest on 06.042016. The conclusion of the Inquest was: Mrs H J Turner was admitted to William Harvey Hospital on 08.04.15 complaining of symptoms of diarrhoea and vomiting which were diagnosed as a sigmoid colon obstruction on 12.04.15. On 20.04.15 Mrs Turner underwent surgery after developing peritonitis_ There was a in reaching a correct diagnosis and a delay in operating on Mrs Turner which, on the balance of probability__has caused or contributed materially to her death on 17.05.15
Circumstances of the Death
Helen Turner was admitted to William Harvey Hospital on 06.04.15 complaining of diarrhoea and vomiting: Initially it was thought that she had gastroenteritis but a CT of the abdomen confirmed diagnosis of sigmoid colon obstruction. It was recommended that she undergo a stenting procedure at Kent & Canterbury Hospital but whilst waiting for transfer on 12.04.15 she deteriorated suffering from sepsis: She was transferred to the Intensive Care Unit where her condition further deteriorated. It was not until 20.04.15 that surgery was carried out which confirmed that she was now suffering from faecal peritonitis as a result of colonic perforation. Hartmann's procedure was undertaken. Helen Turner was transferred to the Intensive Care Unit where she underwent further surgical procedures for abdominal wash out but deteriorated and died on 17.05.16. The cause of death was: 1a) Multiple organ failure 1b) Peritonitis owing to colonic perforation Ic) Large bowel obstruction owing to Adenocarcinoma of the sigmoid colon (operated)
Action Should Be Taken
In my opinion action should be taken to prevent future deaths and believe you have the power to take such action. have written two previous PFD Reports concerning the standard ofl surgery at William Harvey Hospital attended an Individual Review on behalf of the Royal College of Surgeons of_ in September 2015 at the Kent and Canterbury Hospital, Canterbury_ am satisfied that as a result of the review steps have been taken to monitor clinical practice and restrict him from undertaking emergency surgery: understand that he is mentored by a Consultant Surgeon at St Mark's Hospital, London and is reviewed by his College. believe that these steps to safeguard patients should continue until East Kent Hospitals University NHS Foundation Trust in conjunction with the Royal College of Surgeons are satisfied that he no longer poses a threat to his patients
Copies Sent To
Medical Director East Kent Hospitals University NHS Foundation Trust Medical Director _ Surgical Directorate East Kent Hospitals University NHS Foundation Trust President of Royal College of Surgeons 35
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.