Alice Ada Phyllis Dickenson · Prevention of Future Deaths report

On 21/05/2014 I commenced an investigation into the death of Alice Ada Phyllis Dickenson, aged 78. The investigation concluded at the end of the inquest on 21 January 2016. The conclusion of the inquest was Mrs A A P Dickenson was referred to the Endoscopy Unit at William Harvey Hospital under the Rapid Access scheme for investigation of a 3 month history of weight loss and dysphagia. She wrote her relevant medical history of haemochromatosis on the patient questionnaire but the Nurse Endoscopist was not aware of this when she scoped her. He saw a lesion which he decided to biopsy, but which in fact was a gastric varix. This bled, and whilst treated, caused her death on 09.05.14. Mrs A A P Dickenson died at 1205hrs on 09.05.14 at William Harvey Hospital.

Mrs A A P Dickinson died at 1205hrs on 9th May 2014 at William Harvey Hospital.

The cause of death was:-
1a) Gastrointestinal haemorrhage after biopsy procedure (hospital histology)
2 Cirrhosis of the liver, Haemochromatosis, Thrombocytopenia, Degenerative heart disease.

Mrs Dickenson had a history of inter alia haemochromatosis. This was not mentioned on the brief GP referral form for the rapid access scheme. It was, however, mentioned by Mrs Dickenson on the patient questionnaire which she completed which was not transcribed onto the assessment form completed by the Nurse at the Endoscopy Unit. Therefore, the Endoscopist did not have sight of this important medical condition when viewing what he considered to be a lesion which he biopsied. The lesion was, in fact, a gastric varix which bled in spite of treatment to stem the bleeding. Mrs Dickenson died as a result of a gastrointestinal haemorrhage.

That important past medical history may be omitted when referring the patient to the rapid access scheme for an endoscopy. The GP referral form is limited therefore enabling the omission of important medical conditions or history which would assist the endoscopist.