Ann Margaret Cotgrave · Prevention of Future Deaths report

On the 3rd of May 2022 I commenced an investigation into the death of Ann Margaret Cotgrove (DOB 10.08.51 DOD 03.05.22). The investigation concluded at the end of the inquest on the 20th of February 2025. The cause of death was recorded as being due to 1(a) Peritonitis , Acute Liver Failure and Bronchopneumonia 1b Gall Bladder Perforation 1c Endoscopic retrograde cholangiopancreatography due to obstructive jaundice and the conclusion of the inquest was that the death was due to medical misadventure.

The circumstances of the death are that Miss Cotgrave had been admitted to Glan Clwyd Hospital on the 31st of March 2022 and was being investigated to establish the cause of her jaundice. She did not undergo a required ERCP until the 19th of April and on the 22nd of April was found to have sustained a perforation which is likely to have occurred in the course of that procedure. By that time she was too unwell to undergo reparative surgery and she passed away on the 3rd of May 2022.

The delay in her undergoing the ERCP was due (inter alia) to the consultant gastroenterologist requesting that advice from tertiary centre in Liverpool be obtained prior to the procedure due to a suspicion of malignancy. He was subsequently informed that advice had been received indicating the ERCP should be undertaken at Glan Clwyd and he therefore proceeded.

Whilst there is no reason to doubt the veracity of the consultant’s evidence, that advice from the tertiary centre had been sought, there is no documented evidence in relation this.

That there was no record of any discussions which took place between Glan Clwyd and the tertiary centre and no formal documented process in relation to such referrals and the subsequent advice which was provided and thereafter acted upon.