Lynda Pedersen · Prevention of Future Deaths report

On 19th September 2018 I commenced an investigation into the death of Lynda Pedersen age 60. The investigation concluded at the end of the inquest on 26th February 2020. The conclusion of the inquest was a narrative conclusion that Lynda Pedersen died of a complication of an undiagnosed but untreatable adenocarcinoma of the oesophagogastric junction

Lynda Pedersen died on 7th September 2018 on Oxford Ward William Harvey Hospital from aspiration pneumonitis, pneumonia and fluid overload due to a stricture caused by an adenocarcinoma of the oesophagogastric junction against a background of alcoholic liver disease. During the course of her admission she received necessary intravenous fluids but became overloaded with fluid which impacted on lung function. The adenocarcinoma was not identified on this admission or at any earlier time whilst she was under the care of medical practitioners following an admission in September 2017 for dysphagia. The stricture was identified.

(1) Lynda Pedersen was admitted to William Harvey Hospital on 6th September 2017 with dysphagia. A gastroscopy conducted two days later identified a stricture within the oesophagus with the appearance of the mucosa suggestive of a submucosal infiltration. A CT scan did not identify a malignancy but indicated that the area of concern could not be evaluated as it had not been distended by the orally ingested contrast. Lynda Pedersen had a number of further gastroscopies to attempt to dilate her oesophagus between 2017 and 2018 some of which reported a benign appearance but the cause of the stricture was never investigated despite the risk of variceal bleeding having been significantly reduced by a TIPS procedure having been conducted on 11th October 2017. It was accepted that a biopsy should have been undertaken but the need for investigation as to whether there was a malignancy was lost in that the clinicians’ focus was on attempting to improve her nutritional status and quality of life. The reason for the loss of the need for an investigation was twofold: there was no pathway in place for dysphagia presentation caused by a stricture and the fact of multiple presentations. It was agreed by the treating clinicians and an independent expert that had there been a pathway in place, the investigation for cancer was less likely to have been lost. The clinicians who gave evidence at the Inquest were of the view that this was a matter most appropriately addressed by NHS England and NHS Improvements.

(2) Fluid balance charts were not correctly completed in the period leading to Lynda Pedersen’s death. The evidence from the fluid balance charts showed that she was carrying fluids forward until the time of her death; there being an imbalance to the tune of some 3 1/2 litres. That there was a significant fluid overload was also evident from the pathology. That she had a fluid overload was only identified by the hospital at a time that she was temporally close to death. It was accepted at the inquest that the charts were deficient in their completion, that nursing staff had not recorded output properly or reconciled the balance as required.