Helen Jennifer Turner · Prevention of Future Deaths report

On 21/05/2015 I commenced an investigation into the death of Helen Jennifer Turner. The investigation concluded at the end of the Inquest on 06.042016. The conclusion of the Inquest was:

Mrs H J Turner was admitted to William Harvey Hospital on 08.04.15 complaining of symptoms of diarrhoea and vomiting which were diagnosed as a sigmoid colon obstruction on 12.04.15. On 20.04.15 Mrs Turner underwent surgery after developing peritonitis. There was a delay in reaching a correct diagnosis and a delay in operating on Mrs Turner which, on the balance of probability, has caused or contributed materially to her death on 17.05.15

Helen Turner was admitted to William Harvey Hospital on 06.04.15 complaining of diarrhoea and vomiting. Initially it was thought that she had gastroenteritis but a CT of the abdomen confirmed a diagnosis of sigmoid colon obstruction. It was recommended that she undergo a stenting procedure at Kent & Canterbury Hospital but whilst waiting for transfer on 12.04.15 she deteriorated suffering from sepsis. She was transferred to the Intensive Care Unit where her condition further deteriorated. It was not until 20.04.15 that surgery was carried out which confirmed that she was now suffering from faecal peritonitis as a result of colonic perforation. A Hartmann’s procedure was undertaken. Helen Turner was transferred to the Intensive Care Unit where she underwent further surgical procedures for abdominal wash out but deteriorated and died on 17.05.16.

The cause of death was:

1a) Multiple organ failure
1b) Peritonitis owing to colonic perforation
1c) Large bowel obstruction owing to Adenocarcinoma of the sigmoid colon (operated)

• There was a delay in confirming the diagnosis of sigmoid colon obstruction which did not take place until 12.04.15, some four days after her admission to William Harvey Hospital.
• There was a delay in the decision for Mrs Turner to undergo a stenting of four days, by which time her condition had deteriorated thus rendering her unsuitable for this procedure.
• There was a delay in operating on Mrs Turner to remove the bowel obstruction which did not take place until 20.04.15 by which stage her condition had deteriorated to a critical level.
• The expert evidence heard at the Inquest found that Mrs Turner had a 90% chance of surviving the diagnosis of cancer and abdominal surgery to remove the tumour. Because of the delay in diagnosis and surgery, her chances of survival were diminished.