Phyllis Barnes · Prevention of Future Deaths report

On 7th March 2014 I commenced an investigation into the death of Phyllis Barnes, 82 years of age. The investigation concluded at the end of the inquest on. The medical cause of death given was:

1a. Peritonitis
1b. Anastomotic Leakage Post Anterior Resection for Carcinoma of the Colon
1c

2.

My narrative conclusion was:

Mrs Barnes died from a recognised complication of necessary surgery where there was a delay in the recognition of the severity of her symptoms which resulted in a delay in treatment which could have affected the outcome

Mrs Barnes underwent an elective laparoscopic anterior resection for carcinoma colon on 11th April 2013. She was discharged home on the enhanced recovery programme for laparoscopic procedures on 15th April 2013. Mrs Barnes became unwell with vomiting on or shortly after discharge from hospital and her daughter called her GP practice, the Downing Street Group Practice, on the day of discharge because of the vomiting and anti-emetics were prescribed. The Nurse Practitioner from the surgical department called as routine on the 16th April 2013 but reassured Mrs Barnes that ‘it takes time’ when she commented on vomiting and feeling unwell. It is unclear whether there was a subsequent phone call as promised. Mrs Barnes continued to vomit and the GP visited at her daughter’s request but no treatment was instituted or referral made back to hospital. Mrs Barnes continued to deteriorate and she was readmitted as an emergency on 18th April for repair of an anastomotic leak arising from the original procedure but died of these complications at 0530 on 19th April 2014.

1. Failure of visiting General Practitioner to appreciate the seriousness of Mrs Barnes condition in view of her recent operation and persistent symptoms
2. Inappropriate nurse-led telephone consultation for the enhanced recovery programme for laparoscopic surgery appears to have been superficial and perfunctory with doubts over a further telephone follow-up as promised
3. There was no formal communication or opportunity for Mrs Barnes’s daughter to relate her mother’s condition to the GP or the Nurse Practitioner