Carole MCQUINN · Prevention of Future Deaths report

On 16 May 2022 an investigation was commenced into the death of Carole MCQUINN aged 66. The investigation concluded at the end of the inquest on 11 July 2023. The conclusion of the inquest was that the deceased died as a consequence of a recognised complication of necessary surgery to treat pancreatic cancer, namely a pulmonary embolism which was likely to have developed as a result of post-operative infection, inflammation and immobility.

On the 21st of February 2022 the deceased underwent a distal pancreatectomy and splenectomy at St James's University Hospital, Leeds to treat a malignant pseudo papillary tumour. She subsequently developed leaking of fluid from the remnant pancreas which is a recognised complication of this surgery and for which an abdominal drain was sited. She had a prolonged in-patient admission, during which she required periods of intravenous antibiotic therapy to treat abdominal collections, drainage of a pleural effusion and nutritional support via naso-gastric feeding and total parenteral nutrition. Her abdominal drain was removed on the 11th of April 2022. She was discharged home on the evening of the 20th of April 2022 without a discharge note or medication, which were not supplied until the following day. No follow up appointment was booked for the deceased. On the 21st of April 2022 the site of her previous abdominal drain was leaking pus. A swab was taken of the site and booked in to St James’s Hospital for testing on the 22nd of April 2022. The results of the swab were reported on the 26th of April 2022 but not reviewed by a member of the clinical team until the 3rd of May 2022 when oral antibiotics were commenced. On the evening of the 4th of May 2022 the deceased was found collapsed at home and was admitted to York Hospital by ambulance. She was treated for intra-abdominal sepsis and her observations stabilised, but she was found unresponsive in her hospital bed on the morning of the 7th of May 2022.

In respect of concerns relating to St James's University Hospital, Leeds -

1. The deceased was discharged from hospital on the evening of 20th April 2022 with no discharge note, medications or follow-up appointment. I heard evidence that evening discharges are a cause for concern for the Trust itself, and that while consideration is being given to ensuring follow-up appointments are set on discharge, this is not yet currently in place. Trust staff were falsely reassured in this case that the deceased had this safety net in place when she did not.

2. Trust staff interacting with the deceased and her daughter regarding infection concerns arising in the post-discharge period between 21/4/22 and 3/5/22 made no records of the same. Nursing staff were shown photographs of the deceased's drain site, and issued stoma bags and a swab to her daughter for suspected infection, but did not flag this development to the treating team or make arrangements for the results of the swabs to be reviewed. No clinical observations of the deceased were recorded when she attended the hospital on 3/5/22. The swab result did not come to anyone's attention or get reviewed until the deceased's daughter flagged the issue to staff on 3/5/22. These omissions led to missed opportunities for earlier assessment and treatment of the deceased.

In respect of concerns relating to both St. James's University Hospital, Leeds and York Hospital -

3. The deceased had an emergency admission to York Hospital on 4/5/22 with suspected intra-abdominal sepsis. A York doctor was verbally tasked with communicating with the surgical team at Leeds to report back on a comparison of CT scans from both hospitals. No record of this contact - which was verbally reported in positive terms - was made by either hospital and no evidence could be provided as to who had spoken to whom and in what terms. Further, despite the lengthy and complex treatment the deceased had undergone in Leeds, and her attendance there the day prior to admission to York, no contact was made by the treating team at York with the treating team at Leeds, to allow for additional specialist input into the deceased's management and consideration of possible transfer of care.