Marie Bell · Prevention of Future Deaths report

On 7th August 2025 I commenced an Investigation into the death of Marie Bell, aged 58 years. The Investigation concluded at the end of the Inquest on 7th July 2026.

The medical cause of death was confirmed as: -
Ia Faecal Peritonitis
Ib Iatrogenic Small Bowel Perforation (operated)
Ic Obstructing Sigmoid Bowel Cancer (operated)

On 25 July 2025 Marie Bell underwent a procedure to remove a bowel obstruction. There were no noted complications within that surgery however it would appear that during the procedure the diathermy implement has made contact with the small bowel causing a scorch and subsequent perforation which was not noted during the surgery. This perforation was not noted until Marie deteriorated on 27 July 2025 and despite surgery to repair the perforation on 28 July 2025 it was unsurvivable and she died at hospital on 29 July 2025.

I gave the following narrative conclusion: -
‘On 25 July 2025 Marie Bell underwent a procedure to resolve a bowel obstruction. Unfortunately she suffered a perforation of her small bowel as a consequence of the surgery and went on to develop faecal peritonitis resulting in her death on 29 July 2025.’

On 25 July 2025 Marie Bell underwent a procedure to remove a bowel obstruction. There were no noted complications within that surgery, however, it would appear that during the procedure the diathermy implement had made contact with the small bowel causing a scorch and subsequent perforation which was not noted during the surgery. This perforation was not noted until Marie deteriorated on 27 July 2025 and, despite surgery to repair the perforation on 28 July 2025, it was unsurvivable and she died at hospital on 29 July 2025.

The obstruction was directly related to a tumour, located within Marie’s bowel, which had been present in February 2025 when Marie had a positive FIT test, and therefore could have been diagnosed earlier and surgery performed earlier. The reason for not diagnosing cancer in February 2025 is that Marie was physically unable to undergo a colonoscopy due to imminent hip surgery, and the Screening Service deemed her to therefore be declining investigations rather than identifying alternative methods of investigation. This did not make a difference to the outcome for Marie but may for others.

Where one means of investigation is not suitable for a patient due to comorbidities or conditions this does not mean that the patient is declining all investigations and an alternative should be explored.

I shall be glad to be told of any learning arising from Marie’s death and timescales and results of your review.