Calogero Di Blasi · Prevention of Future Deaths report

On 13th December 2022 an investigation was commenced into the death of Calogero Di Blasi. The investigation concluded at the end of the inquest on 15th November 2023.
The conclusion of the inquest was:

The deceased died as a result of a recognised complication of an investigative medical procedure in circumstances where underlying cirrhosis and resultant varices were unknown, and not recognised as a possibility, by the Endoscopist

The cause of death was recorded as:

1a) Haemorrhagic shock
1b) Perforated gastric varix (post surgical procedure)
1c) Portal hypertension due to chronic alcoholic liver disease

On 10 August 2022, Calogero Di Blasi was referred by his GP to the Upper Gastro-intestinal team at the Bristol Royal Infirmary for possible stomach cancer. He underwent an endoscopy on 18 August 2022 where biopsies were taken. The results showed abnormal cells. On 15 September, Mr Di Blasi was referred by a GP to the Lower Gastro-intestinal team for possible bowel cancer and had a CT scan on 4 November 2022. The CT scan revealed cirrhosis with portal hypertension and gastric varices, which were new incidental findings. The Lower GI team had been made aware of the investigations ongoing by the Upper GI team, but the upper GI team were unaware of the Lower GI team’s involvement. Both referrals were made on the 2 week cancer referral pathway. The CT Scan was reported on 14 November, and double reported on 16 November 2022. However, the referring clinician did not review the report until the day after Mr Di Blasi’s death, on 2 December 2022. The incidental findings were not considered to be ‘significant’ by the Radiologists and were not therefore warrant an alert being sent to the referring clinician, leaving the report to be reviewed when they were able to. My investigation revealed that the timeframe for seeing patients on the cancer referral pathway is the date of the first appointment and there are no other target dates in respect of investigations or subsequent treatment.

Mr Di Blasi underwent a further endoscopy on 30 November 2022. The Endoscopist was unaware of these incidental findings. A biopsy was taken from an area which looked abnormal but was actually a gastric varix. As a result of this, Mr Di Blasi suffered a massive bleed and despite maximal supportive measures, he died on 1 December 2022 at the Bristol Royal Infirmary, Upper Maudlin Street, Bristol, BS2 8HW.

(1) That one of the teams caring for Mr Di Blasi was completely unaware of the input from another specialty team, despite both referrals being made under the 2-week urgent referral pathway. The lack of communication between these teams meant that timely sharing of results did not occur. Even the very knowledge of the fact that a CT scan had taken place would have alerted the endoscopist to check those results, and it is likely that the second endoscopy would not have gone ahead. I understand this to be a national issue and is likely to apply to other investigations being carried out.

(2) That the reporting timeframes on the 2-week urgent cancer pathway referral does not take into account timeframes for reporting investigative procedures or subsequent review by the referring clinicians.

(3) The current training for Endoscopists for JAG certification requires the performance of 200 endoscopies. However, these tend to focus on the clinician’s area of specialty and therefore there is a danger that lesion recognition will be limited and insufficient to ensure that endoscopists are able to recognise less frequently occurring lesions. With the need for an increasing number of endoscopists, action should be taken.