Denise Ellen Johnson · Prevention of Future Deaths report

On 26th February 2024 I opened an Inquest into the death of:

Denise Ellen Johnson

The conclusion of the Inquest on 10th December 2024 was:

Dee died from acute small and large bowel infarction secondary to necrotising pancreatitis and intraabdominal sepsis, both recognised complications of severe post ERCP pancreatitis, on the background of obesity, recent treatment for Breast Cancer and severe psychological stress

The medical cause of death was confirmed as:

1a Multi-organ failure
1b Severe E. coli septicaemia
1c Pancreatic necrosis and ischaemic bowel perforation
1d CBD stones and post ERCP pancreatitis

Dee was admitted to hospital as an emergency with abdominal pain and jaundice on 13th August 2022.
Dee was 42 years of age with a history of obesity, ongoing treatment for breast cancer and depression.
Investigations revealed a gallstone in the common bile duct as the cause of her jaundice.
An endoscopic retrograde cholangiopancreatography (ERCP) was performed and a plastic stent inserted for drainage.
Dee became acutely unwell post ERCP and was diagnosed with acute necrotising pancreatitis.
Dee was admitted to ITU for 9 days for supportive care and antibiotics.
The care of Dee’s necrotising pancreatitis and associated peri-pancreatic collections via CT Scans, insertion of abdominal drains, treatment plans and clinical updates was managed at Ipswich General Hospital with ongoing advice and guidance from Addenbrooke’s Hepato-Pancreato-Biliary multidisciplinary team.
Subsequent CT scanning showed severe pancreatitis with fat necrosis and peripancreatic fluid collections.
Dee’s infected peri-pancreatic collections were drained by a series of drains.
Dee had regular pain management, physiotherapy and dietician review. The peripancreatic collections were managed by ongoing abdominal drainage, flushing and antibiotics as guided by Microbiology.
Despite ITU admission with intensive supportive care her condition deteriorated and Dee died on 24th November 2022.

Timely notification to ERCP practitioners following serious complications, with formal case review

ERCP-based endoscopic complications should be presented in a formal setting in the presence of Endoscopy colleagues. There is a need for timely feedback to responsible ERCP practitioners in cases of procedure-based complications to ensure checks and learning on matters such as safety and adherence to guidelines and standard practice.

Regular discussions about management plans and treatment options with NOK/family by a responsible Surgical Consultant for inpatients with serious surgical issues

Plans and management were discussed on the Surgical ward with Dee by the Consultant but there was a paucity of comprehensible and timely communication with the next of kin and rest of the family concerning management plans and treatment options. Two-way feedback in this situation plays a vital role in maintaining patient wellbeing and safety.

Lack of clarity around named Surgical Consultant cover for unexpected leave

It was unclear who was the Surgical Consultant responsible for Dee and her pancreatic disease management when her usual Consultant was off work due to unexpected leave. A clear handover process at Consultant Surgeon level for unexpected leave enables continuation of care between health care professionals and teams with continuity and oversight of treatment and management plans.

Accordingly, I consider that:

Not having timely notification to ERCP practitioners following serious procedure-based complications, and timely associated formal ERCP case review with endoscopy colleagues

Not having regular explanations and discussions with NOK/family by the responsible Consultant concerning ongoing management plans and treatment options for inpatients with serious surgical issues and,

Lack of clarity over named Surgical Consultant cover with responsibility for surgical inpatients during periods of unexpected leave

All pose a significant risk to patient safety.