Dear Mr Siddique Re: Tracey Bannister deceased Date of Birth: 16 th August 1984 Date of Death: 26 th June 2014 Date of Inquest: 20 th November 2014 I am writing in response to your report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. I fully accept that although the inquest verdict on Ms Bannister’s death was natural causes, the circumstance of inadequate discharge information gives nse to the potential for an ongoing risk to future patients. I would like to take the opportunity to assure you that as an organisation. we have formal processes for investigating serious incidents. We have taken this case senously and have conducted a full review. To this end, a Root Cause Analysis was completed which included a review of the systems in place for maintaining safety at the time The learning from both the Inquest and the internal investigation will be shared with staff across the organ isation. Summary of Incident Ms Banrister underwe a repeat elechve E9doscomc Retrograde CholargioPancreatogranhy ERCP) o the 24 Ju e 2014 o ornove a stent Sre c r sented to the rocedure and the o d s 4 ent was removed There were s me agrrents of stone and debNs our.d whic came cut wit th ste enca S we casre eo 0’ toe roe’ arcc i0erc 0e cbee ahoos ;-re. eo’ed .‘t 02 BC ep’rtors D2 aturcrs ‘e ooqca ‘atus and ‘ar eve here a ser ed Tcsevat ‘s tore o k v s r i ver tr ta paarec sa M Ba ret ‘a ‘jLeeucn’Iv c argod / rc wu p . e as o aade to de:vh’ 0’e ma,agemnr off any ern’arts ga cioae, end cTnes C 3 eeos znm At t e tir e o the i de t o B doscopy t sed a d sc arge for at r af e ic M Barr s e was given The eaflet expianed f she contued to fee unwefl or syn’ntons of pain Norsened ther, she should contact her GP n the first nstarce r r’ v’ .I’i Bke tc ar’’ L ca . r’ r,.

Shortly after arrival Ms Bannister went into cardiac arrest, however resuscitation was unsuccessful and she was pronounced deceased at 1O.22hrs Coroners Concerns During the course of the inquest the evidence revealed matters giving rise to concern. In the Coroner’s opinion there is a risk that future deaths will occur unless action is taken. The MATTERS OF CONCERN are as follows,
- There are well documented and recognised risks of ERCP surgery. These include: 1 Inflammation of the pancreas (pancreatitis) 2-4%
2. Infection in the bile duct (cholangitis). This is usually treated with antibiotics, but occasionally can be serious.
3. A hole may be made in the bowel (perforation) and if this happens surgery may be necessary.
4. Bleeding may result from the ECRP. which will usually stop quickly by itself. In severe cases, a blood transfusion or operation may be needed to control the bleeding. The Coroners concern is that patients should be advised not only to contact their GP but also the department where surgery had been performed if symptoms of pain, raised temperature continue for more than 24 hours. In this case medical evidence suggested that had she attended Hospital twenty four hours earlier then the outcome may have been different. Action Taken A Root Cause Analysis was undertaken following Ms Bannister’s death and action was taken with regard to record keeping and observation of patients. Additionally, a review of the discharge information leaflet was undertaken; however we fully acknowledge that the review did not adequately address the risks that have been identified during the inquest. We have therefore revised the leaflet to include clear instruction to patients in line with the Coroner’s recommendations. The leaflet has been approved by the Endoscopy Steering Group. shared with all staff and is now in use. The leaflet is enclosed. Finally, may we take this opportunity to offer our unreserved apologies to Ms Bannister’s family for the inadequate discharge information provided to Ms Bannister following the ERCP procedure, along with our sincere condolences for their lOSS.