Joyce Marchant · Prevention of Future Deaths report

On 4th June 2019 I commenced an investigation into the death of Joyce Marchant. The investigation concluded on the 9th December 2019 and the conclusion was one of Narrative: Died from the complications of a liver abscess where the presence of the abscess was not recognised until an ultra sound on 28th May 2019 and a biopsy to drain it could not be accommodated until 31st May 2019. The medical cause of death was 1a) Multi organ failure; 1b) Biliary sepsis with liver abscess; 1c) Choledocholithiasis

Joyce Marchant had a history of stones in the liver. A series of complex ERCP’s in 2018 removed the stones. A MRCP on 24th January 2019 showed no residual stones. She was seen on 21st May 2019 in the outpatient clinic - liver function tests were normal. She had a raised CRP. That was reported via letter to her General Practitioner (GP). The letter was not received and she was not aware of it. Over the next few days she felt unwell. On 25th May 2019 she went to the Emergency Department at Tameside General Hospital. Her CRP was very high. She was treated for an infection with antibiotics and fluid. An x-ray showed no consolidation. No further tests were carried out until an ultra sound performed on 28th May 2019 at 11:32 am suggested biliary sepsis and queried an abscess. An abscess would not of itself respond to antibiotics and required drainage to reverse the effects. It is probable that she was well enough to undergo a drainage procedure at that time. A review that evening resulted in a CT scan on 29th May 2019. On 29th May she was deemed too unwell to transfer to Manchester Royal Infirmary. The radiologist at Tameside General Hospital could not accommodate a drainage procedure until 31st May 2019. There was no further discussion of the options at that stage. She continued to deteriorate and was placed on end of life care on 30th May 2019. She died at Tameside General Hospital on 1st June 2019.

1. During the course of the Inquest the evidence given was that the delay in offering the drainage procedure was attributable to a shortage of interventional radiologists which meant that the Trust could not accommodate the need for a drainage procedure until 31st May. There was greater availability at tertiary centres but transfers to tertiary centre could take time and not be practicable. The inquest heard that if she had been at the tertiary centre when the abscess was identified she would probably have had the drainage procedure almost straight away;

2. The inquest heard that the Manchester Royal Infirmary use the postal system to provide GPs with information about blood results/follow up information. Faxes are no longer used due to GDPR. The trust propose to move to an email system for notifying GPs recognising that the use of the postal system carries delay and risk of information not reaching the GP(7% was the figure given to the inquest). Their IT system at this time is not capable of this information transfer and the information was that it would be about another 2-3 years before that was achieved. In the interim they would continue to use the postal system;

3. The MRI was the treating centre for Mrs Marchant’s underlying medical problems which led to her deterioration. However there was no evidence of a clear communication strategy or treatment plan involving the DGH and Tertiary Centre. This was attributed in part to the sheer volume of demand on tertiary centres and the extent of support they can provide to DGHs.