Raymond Lee · Prevention of Future Deaths report

On 16ᵗʰ September 2021 I commenced an investigation into the death of Raymond Lee. The investigation concluded on the 19ᵗʰ January 2023 and the conclusion was one of Narrative: Died from complications of treatment for oesophageal cancer and a subsequent oesophageal stricture. The medical cause of death was 1a) Gastrointestinal Haemorrhage; 1b) Aorta-oesophageal fistula on the background of oesophageal stent; 1c) Oesophageal cancer treated by radiotherapy

Raymond Douglas Lee had oesophageal cancer. Due to his underlying health, he was treated with radiotherapy- other treatments were felt to be suitable. He developed an oesophageal stricture as a consequence of the radiotherapy treatment. Dilatation procedure did not lead to an improvement. A biodegradable stent was inserted to try to improve the position. He was in significant pain as a consequence of the stent. Pain is a recognised complication of stenting in these circumstances. He was admitted to Stepping Hill Hospital on 13ᵗʰ September 2021 following episodes of bleeding. A gastroscopy on 14ᵗʰ September 2021 confirmed that the bleeding was from the oesophagus - from an aorta/oesophageal fistula. On the balance of probabilities, the stent had contributed to the development of the fistula. Raymond Douglas Lee continued to deteriorate and died at Stepping Hill Hospital on 14ᵗʰ September 2021.

The inquest heard evidence that oesophageal strictures are a recognised complication of radiotherapy for oesophageal cancers. The implications of them are significant for patients as they can lead to aspiration and as well as significantly impact quality of life. At this time there is only very limited national guidance on how to best treat patients with strictures and limited evidence on which to develop best practice. The evidence given was that careful dilatation by an experienced practitioner was the best approach initially. However, dilatation particularly repeated dilatation carried risk of perforation and needed to be seen as something that could not be continued indefinitely. However, there was limited evidence on what the optimum number of dilatations were and/or when to stop and move to consider stenting.

The inquest heard that stenting of patients in these circumstances has a limited body of evidence regarding the risk. The inquest highlighted that perforation may be a risk in some cases where a stent is used and that needed to be factored into any decision to use a stent.