Gillian Crossley · Prevention of Future Deaths report

On 2nd April 2013 I commenced an investigation into the death of Gillian Crossley aged 76 years. The investigation concluded at the end of the inquest on 29th August 2014.
The conclusion of the inquest was that there were failings in her care and she was discharged home when she should not have been. As a result there was a missed opportunity to detect her deteriorating condition sooner. However, because the mechanism for the insult to the bowel was unknown, it was also unknown if the outcome would have been different.

Mrs Crossley underwent elective bowel surgery on the 18th March 2013. The surgery was technically successful but her recovery period was slower than expected and she was discharged home on the 26th March 2013 but re-admitted the following day in extremis as a result of bowel necrosis and subsequent perforation. Despite further surgical intervention she remained gravely ill and died on the 28th March 2013.

I have received previous assurances from the University Hospitals Leicester that measures have been in place to audit documentation so that it meets professional standards. However, I found the following during this inquiry:
(1) Inadequate documentation
(2) Failure to observe and monitor in accordance with Mrs Crossley's needs
(3) Failure to properly assess the fitness for discharge and properly plan that discharge
(4) Inadequate communication between those who were responsible for the care and treatment of Mrs Crossley