Ronald Smith
PFD Report
Historic (No Identified Response)
Ref: 2015-0207
Coroner's Concerns (AI summary)
There was a failure to provide flexible sigmoidoscopy out of hours, and despite a root cause analysis identifying the need for a protocol, one was still not in place 18 months after the death.
View full coroner's concerns
In the duty to report to you: TeebleATTERS OF CONCERN are that there was a failure in this case to flexible sigmoidoscope out of hours. This item of surgical access a to surgical registrar who considered that equipment was not available benefitted the patient: this was the only intervention that may have iMe Smith'$ death occurred in February 2014. The Trusts root cause identified the need for a clearly communicated and analysis report flexible sigmoidoscopies out of hours. accessible protocol for access to has elapsed since Mr Smith'= death Notwithstanding the period of 18 monthsswhich consider that there is still no protocol in place at the Trust be actior sbould be taken to expedite a ciear procedure for such equipment available to staff out of hours. to
Sent To
- Barking, Havering and Redbridge University Hospitals NHS Trust
Response Status
Linked responses
0 of 1
56-Day Deadline
27 Jul 2015
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 thezth February 2014, ! commenced an Alfred Smith The investigation investigation into the death of Ronald 2015. The conclusion concluded at the end of the Inquest on the 28' of Inquest was a narrative conclusion Mic Ronald Smith presented to Queen's Hospital on the 1" sigmoid volvulus, causing & bowel obstruction February 2014, with a unwell on admission. Surgical and bowel ischaemia. He was severely his acute condition and rintervention was not considered appropriate, insvieerer relievuteis ondipomrandas -orxioieieia The only procedure considered appropriate to flexible sigmoidoscope a flexible sigmoidoscopy: It was not possible to access the passed away at 09.40 theznight and Mr Smith'$ condition deteriorated He Pheseck oranetiexible Gigthoidoscobruary 2014 before the procedure nadeaken place; intervention which hsigmoidoscope resulted in a lost opportunity fo provideen might have avoided his death.
Circumstances of the Death
Mic Smith was admitted to Queens Hospital on the 1s distended abdomen and evidence of metabolic' February 2014 with a severely derangement He was reviewed by the acidosis, hypertension and kidney diagnosis sigmoid volvulus with bowel surgical registrar who considered the likely was confirmed by CT scan. obstruction and bowel ischaemia, This diagnosis consultant surgeon and it was surgical registrar discussed Mr Smith with the view of Mr Smith's acute agreed that a laparotomy would not be appropriate in prospeci ofSmopefat ineerperticorwasd ~o-vaorbiditieer It was agreed the only sigmoidoscopy was was by way of an endoscopic decompression: rigid shgtnne oncgpyrther aptonpted butaotpossible to the It was considered optionevailablette1Piottafheflexrbie sigmoidoscopy This was the only treatment sigmoidoscope Smith. TThe surgical registrar made efforts to locate & flexible attempting by contacting the night theatre staff; contacting tthe Ioedicaa Eo access the endoscopy nurses and speaking to ne registrar; also obtained access to the clinical decision unit gastroenterologist He sigmoidoscope would be with the assistance where he believed the flexible flexible sigmoidoscope could not be of the night manager and security. "Geoggeoidoospitel foirl natbecobtaoteac The endoscopy nurses contacted were Queen's The switchboard did not know were the equipment was kept at Queens's hospital_ No rotcppear to be able to contact the endoscopy nurses at consideration was given to obtaining the equepaescorom Way, Coroner May the during The that due blockage. King King
Geergiee hospital A plantwas eventually agreed for Mr Smith to undergo the procedure takerg peacadoscopy day team arrived Sadly he passed away priorderge peodederd place. Aepost-mortem examination was carried out and the cause of death be: was confirmed to Ia; Intestinal infarction 1b; sigmoid volvulus 11; Hypertensive and Ischaemic Heart
Geergiee hospital A plantwas eventually agreed for Mr Smith to undergo the procedure takerg peacadoscopy day team arrived Sadly he passed away priorderge peodederd place. Aepost-mortem examination was carried out and the cause of death be: was confirmed to Ia; Intestinal infarction 1b; sigmoid volvulus 11; Hypertensive and Ischaemic Heart
Action Should Be Taken
Tromg opinion action should be taken to prevent future deaths and power to take such action; believe you have the
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Data sourced from Courts and Tribunals Judiciary under the Open Government Licence.