Lorraine Sandra Parker · Prevention of Future Deaths report

The family requested me to refer to the deceased as Lorraine. I will reflect that in this report. I conducted an inquest into the death of Lorraine Sandra Parker which concluded on 3rd April 2025. She was 52, and died on 30th March 2024. I recorded a narrative conclusion as follows:

Natural causes, contributed to by cancer, by necessary surgical treatment, and by delay in diagnosing and managing anastomotic leak, after surgery conducted on 23rd of January 2024.

This can be summarised by my findings on the Record of Inquest as follows:

Lorraine Parker had an operation for sigmoid colon cancer on 23rd of January 2024. Although there was some improvement in the patient’s clinical condition, there was a delay in investigating clinical signs and blood markers, specifically CRP results, from 27th of January 2024. Lorraine was discharged home on 31st of January 2024 with no post-operative scan and a CRP of 173. The CRP result had been increasing over the past three days before her discharge.

On return to hospital on the 1st of February, her CRP had continued to rise and a CT scan was carried out. The scan was misreported as showing no anastomotic leak. It was only when faeces began to leak from her wound that the scan was re-reviewed and noted to show anastomotic leak. She was initially managed conservatively, but was then returned to theatre. Her disease colon was noted to be disintegrated.

Lorraine was managed on the intensive care unit between 5th and 14th of February, and on a ward thereafter before being discharged home on 23rd of February. She was re-admitted to hospital between 12th and 15th of March, when a drain was inserted to remove a pelvic collection.

When attending a routine wound review appointment on 30th of March 2024, Lorraine became suddenly unwell. The crash team attended and resuscitation efforts were carried out, but she died that day, at Royal Berkshire Hospital, Reading in Berkshire.

Her cause of death was:

1a Pulmonary embolism
1b Deep Vein Thrombosis
2 Sigmoid colon adenocarcinoma (operated January 2024)

I concluded that delay in diagnosing and managing anastomotic leak contributed to her death.

1. It is clearly the case that clinical judgement is the most important factor in deciding when a patient who has undergone major abdominal surgery requires a CT scan. Surgeons will “treat the patient, not the numbers”.
2. There is currently no guidance which requires surgeons to consider scanning for patients who have undergone major abdominal surgery and whose CRP is high and not decreasing, as was the case here at the time Lorraine was discharged from hospital on 31st January 2024.
3. There may be some difficulty in creating a hard line requirement for CT scanning based on a particular CRP result, but I am concerned that there is no guidance in place for requiring a consultant to consider this – perhaps when the CRP is above a certain figure and either not decreasing or continuing to rise. Any such guidance could still allow for clinical judgement – and documenting of the reasons for that decision.
4. It is my experience that clinical judgement alone, particularly where a patient looks well “from the end of the bed” is not always sufficient in this scenario. I have seen a number of avoidable death cases in this context. The purpose of blood test results is to flag up objective areas of concern. There is much reference to chasing up CRP results in Lorraine’s records, but these do not appear to have been taken into account at the time that she was discharged from the hospital without a post-operative scan.