Mrs. Susan Longden · Prevention of Future Deaths report

On 26th February 2018 I opened an Inquest into the death of Mrs. Susan Longden age 69 years. The inquest was heard 26th - 28th November 2018. The conclusion was that the medical cause of death was
(a) Acute intra-abdominal haemorrhage; (b) Splenic injury ascribed to recent colonic perforation during colonoscopy
The conclusion as to the death was: The Deceased died after suffering a very rare complication of a routine, but necessary, colonoscopy.

The circumstances leading up to Mrs. Longden’s death are that on the morning of 31st January 2018 Mrs. Longden attended Weston General Hospital where she underwent a routine surveillance colonoscopy. This procedure was performed by a Nurse Endoscopist. She was discharged from hospital at around 12:00 hours approximately one hour after the procedure was completed.

During the early afternoon that same day Mr. Longden, the deceased’s husband, telephoned the Endoscopy Unit and spoke to a staff nurse and reported that his wife was experiencing abdominal pain and requested some advice. The staff nurse advised she be given paracetamol tablets and a drink and she also spoke with Sister on the Endoscopy Unit who, in turn, telephoned Mr. Longden. Mr. Longden reported his wife's pain scored 9/10.

Mrs. Longden had taken the paracetamol tablets and Sister telephoned Mr. Longden again approximately 45 minutes later at around 15:00 - 15:15 hours and was advised Mrs. Longden’s pain was now 8/10 and she was feeling slightly better. The Sister made a further telephone call at around 16:10 hours when the pain was scored at 6/10 and Mrs. Longden reported feeling slightly better. At around 18:45 the Sister made a further call and Mrs. Longden reported the pain was 5/10 and she was feeling better.

Mr. Longden states that his wife went to bed at around 20:00 hours and shortly afterwards she started yelling out in pain. He telephoned NHS 111 (operated by Care UK) at 20:53 hours. The call was taken by a non-medical Health Advisor (1) who followed the NHS Pathways computerised triage tool. The Health Advisor was told that she could not speak to Mrs. Longden and therefore all information was provided by Mr. Longden. At the conclusion of the telephone call the outcome generated was that a Category 3 ambulance was to be called. In accordance with the procedures of the NHS 111 service this required approval by a Clinical Advisor (a nurse). The call was passed to the Clinical Advisor who spoke with Mr. Longden and arranged for a doctor to call within two hours rather than a category 3 ambulance.

A short while later at 21:41 hours Mrs. Longden became unresponsive and after calling NHS 111 (operated by Care UK) again a Category 1 ambulance was called immediately and arrived at around 21:49 hours. The paramedics confirmed she was in cardiac arrest. At 22:40 hours there was return of spontaneous circulation but she suffered a further cardiac arrest at 22:50 hours. Subsequently Mrs. Longden was taken to the Emergency Department of the Bristol Royal Infirmary where she arrived at 00:05 hours (1st February 2018). She had had a prolonged period of cardiac arrest and this was deemed an unsurvivable event and she was pronounced deceased at 02:00 hours.

(1) The NHS Pathways algorithm does not include a question with regard to recent surgical or interventional procedures where a patient is reporting severe abdominal pain. The close association in time between such a procedure and the onset of symptoms may well be significant in ensuring prompt action is taken to investigate the cause of the symptoms.
(2) Where the caller to NHS 111 is not the patient then the Health Advisor continues to follow the algorithm by obtaining information from the caller and not the patient. There should be greater emphasis on trying to speak with the patient and the information provided reason(s) why the patient cannot came to the telephone. The information provided by the patient themselves and the manner in which that information is provided may well affect the outcome of the triage process.
(3) During the course of the Inquest I heard evidence from ████████ the Medical Lead, SW111 Care UK, that concerns have been raised with your organisation on previous occasions. The case references provided by ████████ are P130273, P132849 and P133040