Clara Novella Winter · Prevention of Future Deaths report

On 12ᵗʰ. December 2022, I commenced an investigation into the death of Clara Novella Winter, aged 77. The investigation concluded at the end of the inquest on 17ᵗʰ. May 2024. At the conclusion of the inquest, the medical cause of death was established as.

1a Perforated incarcerated ischaemic bowel
1b Intra abdominal adhesions in the setting of elective cholecystectomy (operated on 14/11/2022) and previous pelvic surgery

My conclusions were that Clara Novella Winter died at Prince Charles Hospital on 19ᵗʰ. November 2022 as a result of a perforated incarcerated ischaemic bowel.

I reached a narrative conclusion that following routine and uneventful surgery to remove her gall bladder, Mrs. Winter's bowel became inflamed and resulted in complications with her existing hernia, including further adhesions, incarceration of the bowel, ischaemia and a bowel perforation. Emergency surgery was carried out to repair this but sadly Mrs. Winter was unable to recover.

Mrs. Winter was admitted to hospital on 14ᵗʰ. November 2022 for an elective laparoscopic cholecystectomy. She had undergone surgery some years ago which had resulted in complications, including an irreducible hernia and adhesions. Her condition deteriorated the following day, reaching crisis point at around 23:00. Subsequent emergency surgery revealed that whilst the upper abdomen area was normal, the existing hernia had changed, an ischaemic patch had developed along with a bowel perforation. A right hemi colectomy with side to side anastomosis was necessary. Mrs. Winter survived the surgery but later died.

Following Mrs. Winter’s death, her family raised concerns about her post operative care. I did not find that her post operative care more than minimally contributed to Mrs. Winter’s death. However, following an internal review:

1. The Health Board accepted that significant learning was required by staff regarding timeliness of escalation and maintenance of fluid balance charts and recommended that all registered nurses from surgical wards should attend an ‘Acutely Unwell’ study day, before the end of 2023.

2. This ‘significant learning’ has not been fully rolled out due to resourcing issues. No completion date could be provided to me because the training is not considered to be compulsory.