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Investigation and inquest
On 19th April 2023 I commenced an investigation into the death of Marion May Luckraft aged 84. The investigation concluded at the end of the inquest on 11th September 2023. The conclusion of the inquest was a short-form conclusion of natural causes.
The medical cause of death was found to be;
1a Shock due to biliary sepsis
1b Retroperitoneal duodenal perforation following endoscopic retrograde cholangiopancreatography (ERCP) and placement of pancreatic stent.
1c Biliary obstruction due to upper gastrointestinal malignancy
Circumstances of the death
Mrs Luckraft was admitted to hospital on 31/3/23 with jaundice.
Diagnostic tests suggested an obstructed biliary system, an ultrasound scan showed a dilated common bile duct (CBD).
Further imaging occurred on 2/4, a CT abdomen with findings suggestive of CBD stricture and possible malignancy. A MRCP (Magnetic Resonance Cholangiopancreatography) provided a corroborative result on 4/4.
On 11/4 an ERCP (Endoscopic Retrograde Cholangiopancreatography) was undertaken and an unsuccessful attempt to insert a stent into the CBD was undertaken. A stent was inserted in the pancreatic duct.
A CT scan 13/4 on showed a duodenal perforation by displaced biliary stent with retroperitoneal gas/fluid.
A number of factors; the patient’s deterioration, an attempt at drainage through interventional radiology, and discussion regarding which hospital site should be utilised, led to delays in transferring the patient to another hospital for a laparotomy and washout which occurred on 16/4.
The patient passed away on 17/4/23 on ITU.
Coroner’s concerns
1. Cumulative delays in the execution of diagnostic processes and treatments of the patient probably increased the risk of Mrs Luckraft developing biliary sepsis.
2. Following the duodenal perforation suffered by the patient there was a failure to promptly escalate her care to a high dependency unit despite her NEWS score of 8.
3. The fragmentation of the patient’s treatment across two sites of the Trust contributed to delays in her treatment.
4. The absence of a clear and workable treatment pathway for biliary sepsis contributed to delays.
Information checked against the published report and official responses