Geoffrey Ellis · Prevention of Future Deaths report

On 14th September 2015 an investigation was commenced into the death of Geoffrey Ellis who died while in-patient at Stepping Hill Hospital on 8th September 2015.

The investigation concluded with an Inquest held on 12th January 2016 and 24th April 2016.

The conclusion of the Inquest was:
Misadventure contributed to by neglect

Medical cause of death Ia Aspiration pneumonia
b Vomiting secondary to Pseudo-Obstruction of Small Bowel
c Recent Laparoscopic Nephroureterectomy for Kidney Tumour and Chronic Peritoneal Adhesions
II Coronary Artery Atheroma, Hypertension

On 3 September 2015 Geoffrey Ellis was admitted to the Urology Department, Stepping Hill Hospital under the Consultant Care of ████████ Consultant Urologist. Geoffrey Ellis was to undergo a left sided laparoscopic nephro-ureterectomy, removal of kidney and ureter.

The operation was carried out on 3rd September 2015 and to all intents was uneventful and a success, albeit that it was necessary to complete the operation by means of open laparotomy. Geoffrey Ellis was admitted to Ward C6 that evening.

I found that a failure to exam Geoffrey Ellis’ abdomen and to detect distension, on and from 6th September 2015 and to treat hiccups possibly present for 24 hours but in any event present from the morning of 7th September until the late evening contributed either in combination or singularly, to Geoffrey Ellis’ death on the morning of 8th September 2015.

Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway.