Alan Andrew SOANE · Prevention of Future Deaths report

On 30 June 2023, an investigation was commenced into the death of ALAN ANDREW SOANE, then aged 84 years. The investigation concluded at the end of an inquest, heard by me, on 18 March 2024.

The inquest concluded with a short narrative conclusion. The medical cause of death was:

1a intra abdominal sepsis and haemorrhagic shock
1b anastomotic leak following pancreaticito-duodenectomy (performed 05/06/2023).

Mr Soane was an otherwise fit and healthy 84 year old man. The circumstances of his death are recorded in the short narrative conclusion that I reached at the inquest, which was:

“Mr Soane underwent an endoscopy and biopsies at his local hospital in Essex in March 2023, which included a duodenal biopsy. The result of the duodenal biopsy was reported as, ‘Findings are highly suspicious for malignancy, most likely differentiated adenocarcinoma. Immunohistochemical study is requested, and a supplementary report will follow.’ As a result, Mr Soane was referred to the Royal London Hospital on a cancer pathway. A multidisciplinary team (MDT) meeting at the Royal London Hospital on 3 May 2023, concluding, among other things, ‘diagnosis: duodenal cancer (biopsy-proven).’ That meeting was undertaken without further biopsy or tests being undertaken. It transpires that the conclusion was not correct.
Based on the outcome of the MDT meeting, Mr Soane was given a cancer diagnosis and agreed to complex surgery known as a ‘Whipples’ procedure, which was undertaken on 5 June 2023. Mr Soane died on 26 June 2023, as a direct result of known complications of the Whipples procedure. Mr Soane’s surgeon would not have offered him the Whipples surgery had it not been for the incorrect diagnosis provided.”

(1) The NHS Trust in this case was, and remains, unable to provide for the presence of a Consultant Histopathologist at Hepato-pancreato-biliary MDT meetings. It was acknowledged that this was a factor that led to Mr Soane being given a cancer diagnosis that was incorrect. This inability to provide a Consultant Histopathologist is something that has been on the Trust’s risk register for over five years and recruitment exercises have taken place, to no avail. I was told in evidence that this is attributed to the fact that nationally, 25% of Consultant Histopathologist roles remain vacant; in short, there is a national shortage of Consultant Histopathologists.

The concern here is that a national shortage of Consultant Histopathologists puts a widespread proportion of the patient population at a significant risk.

I was reassured that the individual NHS Trust had made continued efforts to reduce the risks they identified, by attempting to recruit to the vacant post. However, I was not reassured that action has been taken at a national level to address the shortage generally.