Kelly Patrick WILLIS · Prevention of Future Deaths report

On 15 September 2014 I commenced an investigation into the death of Kelly Patrick WILLIS. The investigation concluded on 25 March 2015. I reached a narrative conclusion, a copy of which is attached.

Kelly Patrick Willis underwent ablation for atrial fibrillation at St Thomas’ Hospital on 8th October 2012. He was discharged the following day. Dr ████████ the Consultant Cardiologist and Electrophysiologist who operated on him emailed Dr ████████ Consultant Cardiologist at William Harvey Hospital on 10th October and advised her that if Mr Willis began to feel unwell after a period of one week that he should be contacted to have the complications (e.g. atrial oesophageal fistula).

Mr Willis developed symptoms of general unwellness which required him to be admitted to William Harvey Hospital on 14th October, 22nd October and 25th October. On the first and third admission it was noted on admission that he had undergone a procedure at St Thomas’ Hospital who should be contacted. In spite of this documentation, it was not until Dr ████████ reviewed the patient on 29th October that contact was made with St Thomas’ Hospital. Dr ████████ was unable to account for when she read Dr ████████ email and the Ward Clerk, at the end of the second admission, was requested to fax a copy of the Electronic Discharge Notification to St Thomas’ Hospital but failed to do so for a further seven days until 30th October.

The cause of death was:

1a) Cerebral infarction
1b) Multiple septic emboli
1c) Atrio-oesophageal fistula complicating atrial ablation (08.10.12) for paroxysmal atrial fibrillation.

• Those caring for Mr Willis at William Harvey Hospital recognised the need to contact St Thomas’ Hospital about the procedure that he had undergone there but failed to liaise with the tertiary centre before 29th October, even though this was well documented in the medical records on the first and third admissions that it should be. I am of the opinion that contact with the tertiary centre which had operated on Mr Willis should have been made when he first presented at William Harvey Hospital on 14th October, and thereafter on 22nd October and on 25th October as Dr ████████ had requested.
• Dr ████████ did not act on the email sent to her by Dr ████████. Had she liaised with him it is likely, given his flu-like illness and increasing white cell count, that he would have been investigated with CT imaging either at St Thomas’ Hospital or William Harvey Hospital at an earlier stage than 29th October, thus allowing the opportunity to Dr ████████ to exclude rare complications, as he requested in his email to Dr ████████.