Recurring concern

Failure to reliably prevent and detect defective surgical anastomoses

First to latest report 3 Mar 2014 — 29 Apr 2015

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
2

What this concern includes

Includes failures specifically concerning the integrity, safety assessment, detection or early response to defective or breaking-down surgical anastomoses, including ileo-ileal and other gastrointestinal anastomoses where the anastomotic condition is the material safety concern.

What is not included
  • Excludes general surgical errors, postoperative complications or delayed clinical review where no defective or breaking-down surgical anastomosis is identified.
  • Excludes routine wound, infection, discharge or postoperative-care deficiencies that are not specifically connected to anastomotic integrity or detection.
  • Excludes failures occurring after an anastomotic defect has been reliably detected and appropriately escalated, unless the asserted deficiency remains part of the anastomosis-safety process.
  • Excludes non-surgical joins, device connections and unrelated gastrointestinal conditions without a surgical-anastomosis safety concern.

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North West Wales

    AI-generated summary

    Barry Wilson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Wilson underwent a right hemicolectomy and was discharged from hospital on 24 December 2014. He collapsed at home after discharge and died at Ysbyty Gwynedd, Bangor, on 25 December 2014; the recorded cause of death was peritonitis following anastomotic breakdown. The concern was that the defective anastomosis should have been detected before or at discharge, and that earlier detection might have prevented his death.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to detect a defective surgical anastomosis before hospital discharge

    Wider context from the report

    “(1) It would appear from the evidence that the deceased had undergone a right hemicolectomy and that the anastomosis had been made with staples. The anastomosis was defective and this should have been apparent either on or prior to the deceased's discharge from hospital. If the defect had been detected at that stage Mr. Wilson might not have died. ”

    Source location

    Barry Wilson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement a pre-discharge checklist for all patients leaving the Colo-Rectal Ward.

    Verbatim wording from the response

    “This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place”

    Source location

    2015-0167-Response-by-University-Health-Board
    Page 2 · response
    Published 29 April 2015

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require all other Glan Clwyd surgical wards to develop and implement appropriate discharge checklists.

    Verbatim wording from the response

    “This being the case we will by (unless otherwise specified) the 6th July ensure the following are in place”

    Source location

    2015-0167-Response-by-University-Health-Board
    Page 2 · response
    Published 29 April 2015

    Open published response

  2. Central and South East Kent

    AI-generated summary

    Margaret Joy Easterfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Margaret Joy Easterfield underwent reversal of an ileostomy loop, developed peritonitis after an anastomotic leak following surgery, and died after readmission to hospital. The concern was that the anastomotic breakdown may have involved technical error and could raise risks of further deaths.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Ileo-ileal anastomotic breakdown

    Wider context from the report

    “I am concerned that Mrs Easterfield underwent surgery on 26th October 2012 following which there was an anastomotic leak. She was discharged from hospital on the 30th October and was readmitted on 31st October, becoming profoundly unwell in the afternoon of the 3rd November and dying on the 4th November. I consider that a leak of ileo-ileal anastomosis is relatively rare and raises the question of technical error on the part of the surgeon. Because of my concern about the incidences of an anastomotic breakdown, I am raising this matter with you as I believe you can carry out action to prevent further death. ”

    Source location

    Margaret Joy Easterfield · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026