Marjorie McEVOY · Prevention of Future Deaths report

On 05 September 2023 I commenced an investigation into the death of Marjorie McEVOY aged 64. The investigation concluded at the end of the inquest on 02 February 2024.

The cause of death found was:

1a Gastrointestinal haemorrhage

1b Treatment for squamous cell carcinoma

II Bronchopneumonia and Chronic Obstructive Pulmonary Disease

The conclusion of the inquest was that:

Marjorie McEVOY died from a misadventure namely a rare but recognised complication of treatment for cancer.

Mrs Marjorie McEvoy had a medical history of chronic obstructive pulmonary disease, Rheumatoid arthritis and Anal squamous cell carcinoma T2N1. She was on radical treatment with Capecitabine and Mitomycin for radical intent. The cycle commenced on 10/07/2023. Afterwards developed severe mucositis with led to her poor oral intake, diarrhoea and tongue swelling. She was seen by advanced nurse practitioners as well as consultant oncologists. She was admitted in hospital and given antibiotics, IV fluids and supportive care. She also presented Pancytopenia, which was more likely than not chemotherapy related. During admission developed a gastrointestinal bleed related to mucositis. She had multiple blood transfusions and investigations. She recovered initially however had further gastrointestinal bleed on 18th August 2023. She was certified as having died at 04.05 on the 21st August 2023. It is more likely than not that her severe reaction to the treatment was such that stopping the treatment was unlikely to have prevented her death. The quality of the clinical notation from advanced nurse practitioners did not put the oncology team in the best position to react to her care needs.

During the course of this investigation it became apparent that the clinical notation by advanced nurse practitioners were inadequate in that they did not explain the patient’s presentation to enable escalation of care. These notes should be to a similar standard as those of doctors.