Dorothy Cooper · Prevention of Future Deaths report

On 13/01/2015 I commenced an investigation into the death of Dorothy Cooper, 75. The investigation concluded at the end of the inquest on 21 October 2015. The conclusion of the inquest was Narrative conclusion - Dorothy Cooper underwent elective surgery on 29th September 2014. Complications from this surgery led to ischaemia of the liver with areas of infarction which had resolved by the time of her death. The operative procedure, complications there from and associated poor nutritional status, rendered Mrs Cooper more susceptible to developing infection which led to overwhelming sepsis, from which she died on 6 January 2015. The cause of death was: 1a. Sepsis; 2. Elective laparoscopic cholecystectomy and fundoplication; splenic injury; ischaemia and infarcted liver; poor nutritional status.

On the 29th September 2014 Mrs Cooper underwent elective laparoscopic cholecystectomy and fundoplication. Splenic injury occurred at the time of surgery which required laparoscopic repair two days post operatively. Ischaemia to the liver led to infarction and areas of infection which resolved by the time of Mrs Cooper’s death. However, post operatively she remained in a much weakened condition, she struggled to eat and had increasingly poor nutritional intake and also underwent investigations for carcinoma of the liver with ultimately the conclusion being abnormal changes seen on radiology were likely to be linked to an infective process. On the 4th January 2015 due to Mrs Cooper’s extremely poorly state, she was readmitted to the Doncaster Royal Infirmary where she underwent an acute deterioration on the 6th September and she died in hospital on that date.

During the course of the evidence it became clear that when Pinderfields Hospital (the Mid Yorkshire Hospital Trust) referred Mrs Cooper to the Leeds Hospital Trust to investigate the possibility of a liver carcinoma, there was a failure to provide key Information to the receiving team. The information omitted related to blood tests, full radiological evidence and key stages in Mrs Cooper’s recent medical history. It was clear that had that information been provided, the clinical picture would have pointed more towards an infective process having been responsible for Mrs Cooper’s condition rather than a cholangiocarcinoma and thus alternative management was indicated. The receiving team at Leeds identified in their first multi-disciplinary team meeting that there was insufficient information provided in terms of clear clinical parameters but failed to proactively pursue this.

My concern is that it is not effective training for junior doctors completing the referral form and systems for ensuring that key information is identified and transferred to the receiving team, and also that the receiving team have systems in place for ensuring any gaps in the knowledge are filled, then patients will continue to be at risk in the future where management and treatment plans are devised on the basis of an incomplete clinical picture.

Matters of concern in summary are :

1. The absence of clear procedures for those in MDT meetings to proactively follow up inadequately completed referral forms.
2. Lack of procedures to proactively obtain information to complete gaps in clinical history