Prevention of Future Deaths report – William Doleman, Anita Burkey, Peter Sellars and Carol Cole (23 December 2021)

Summary

This Prevention of Future Deaths report relates to the death of four patients who all died from endoscopic retrograde cholangio-pancreatography (ERCP) related complications, within a six-month period. All four patients had their treatment carried out by the same doctor during his training for this high-risk procedure.

In her report, the Coroner Laurinder Bower raises concerns about the systems in place to gain consent and inform patients of the risks of these procedures.

Content

In this report, the Coroner states her concerns as follows:

• There is no robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.
• The lack of robust system for the recording of the vetting of the procedure, capturing information that has been considered as part of this process.
• Consent is not personalised, contrary to recommendations made by the European Society of Gastrointestinal Endoscopy in December 2019.
• A lack of accountability between professionals for ensuring robust vetting and consent.

This report was sent to Nottingham University Hospitals NHS Trust, the British Society of Gastroenterology, the Joint Advisory Group on GI Endoscopy and the European Society of Gastrointestinal Endoscopy.