Abiodun Adisa ORITOGUN · Prevention of Future Deaths report

I opened an inquest on the 24 September 2020, into the death of Mr Abiodun Adisa ORITOGUN on 8th July 2021 in hospital (████████) and concluded the inquest at Southwark Coroners Court on the 12 July 2021. The medical cause of death was: 1a Cardiac arrest 1b Aspiration pneumonia 1c Ileus and pancreatitis. The conclusion as to the death was complications of pancreatitis, Mr Oritogun died of complications of pancreatitis and ileus, contributed to by a failure to escalate review of his care plan the day before he died, which was a very busy one

Mr Oritogun had severe acute pancreatitis for which he was admitted on 4th July 2020 and treated in the ward with analgesia, IV fluids and oxygen. He deteriorated and on the 7th had a peri arrest, with high CRP, tachycardia, high BP, pyrexia. His condition was not escalated for review and he became agitated and paranoid. He removed his NG tube and collapsed breathless whilst self-discharging in a corridor. Resuscitation was unsuccessful. He died of aspirational pneumonia.

The coroner found that there were two concerns about medical care, namely

1. He was considered to be in alcohol withdrawal, (which evidence was not concluded either way) but there was an inadequate care plan with regard to monitoring and observations following his MEWS score rising from 1 to 10 and having a peri-arrest, which should have triggered formal ITU referral (he was seen by outreach nurses) and should have led to finding a cause of his deterioration and subsequent agitation and implemented closer monitoring. The reviewing doctor has reflected and embraced learning.

2. The consultant surgeon gave evidence that Mr Oritogun had a significant risk of arrhythmia related to electrolyte disturbances, although the evidence admitted was that these had been corrected prior to death. She nevertheless concluded that he died of a cardiac arrhythmia, which was not accepted as proven by the court, although it remained a possible cause. She opined that all cases of severe pancreatitis should be cared for in ITU, as they were at risk of sudden death, and they needed a degree of monitoring and observation not available on the general ward. She regretted that she had to accept the decisions of the ITU and informed the court that there may be preventable deaths that occur from not being given care in ITU. She gave evidence that other hospitals had a policy of admitting severe pancreatitis to ITU. Only when evidence of the Trust ITU consultant was admitted, suggesting that requirement of organ failure support was usually needed for admission. The surgeon’s testimony was given despite the Trust embarking on discussions between ITU and General surgery about the matter over the past year.

Whilst the Trust has an Action Plan to consider these matters, it has not been fully implemented a year after death and it is not clear that
a) it will ensure that patients with severe pancreatitis secure adequate monitoring and observations, whether in ITU, HDU or the ward
b) in determining the appropriate criteria for admission to ITU, that they will not be driven by ITU capacity constraints if it is clinically inappropriate to provide a lower level of care.