Shirley Anne Nightingale · Prevention of Future Deaths report

On 21st May 2019 I commenced an investigation into the death of Shirley Anne Nightingale. The investigation concluded on the 21st November 2019 and the conclusion was one of Narrative: Died from the complications of a gastro-intestinal haemorrhage contributed to by neglect. The medical cause of death was 1a) Gastro-intestinal haemorrhage

Shirley Anne Nightingale had Crohn’s Disease which had resulted in an inflammation that was treated with a reducing dose of steroids - a recognised treatment. On 19th May 2019 she had both haematemesis and haematochezia and went to Tameside General Hospital. An Accident and Emergency an upper gastro-intestinal bleed was diagnosed and an urgent endoscopy requested. Guidance indicated this should take place within 24 hours. In the early hours of 20th May 2019 she had a further episode of bleeding. On 20th May 2019 it was identified she was not on the list for an endoscopy. It is unclear why not. She was a high risk patient. It was agreed by the clinicians that it could take place on 21st May 2019 outside the guidance period.

At 7pm on 20th May 2019 she suffered a catastrophic bleed and died at Tameside General Hospital. Post mortem found the source of the bleed was the lower oesophagus and stomach. She had excisions and ulcers at the gastro/oesophageal junction which had caused the bleed on 20th May 2019. An endoscopy within the 24 hour timescale would have identified them and led to urgent investigation and on the balance of probabilities avoided the bleed on the evening of 20th May 2019.

1. The inquest heard that there was no clear system for escalation /prioritisation by treating clinicians in relation to management of the OGD lists and patient need where the OGD team said there was no capacity;

2. The inquest heard that it had been identified in Accident and Emergency that the OGD was required. The notes were marked accordingly but there was no clear system to ensure that this was followed up prior to the ward round on AMU the next day;

3. When a decision was made to depart from the recognised best practice timescales the rationale was not recorded and there was no system to ensure that a suitably experienced clinician agreed with the decision.