Mr Raymond Edwards · Prevention of Future Deaths report

On 14 November 2016 I commenced an investigation into the death of Mr Raymond Edwards, aged 69. The investigation concluded at the end of the inquest on 23 January 2017.

The conclusion of the inquest was: NARRATIVE CONCLUSION- On 24 November 2015 Mr Raymond Edwards was operated for Terminal Ileum. He developed an anastomatic leak which was operated on 1 December 2015 but Mr Edwards died from sepsis and multi organ failure on 2 December 2015 at Ysbyty Glan Clwyd.

Mr Raymond Edwards was initially admitted to Glan Clwyd Hospital on 17 June 2015 and underwent a laparotomy for ischaemic bowel secondary to small bowel volvulus. He was discharged on 2 July 2015. Histology of the excised bowel was undertaken and revealed the rare disease amyloidosis. This histology result was never received by the named consultant and the disease was not followed up.
Mr Edwards was re admitted to Glan Clwyd Hospital on 13 November 2015 after feeling generally unwell. On 24 November 2015 Mr Edwards was operated upon and his appendix removed and a small area of ischaemic bowel excised and a primary anastomosis. By the date of this operation the relevant department were aware of the amiloidosis. By 1 December 2015 Mr Edwards’ condition rapidly deteriorated suggestive of an anastomotic leak. This was operated on 1 December2015 but Mr Edwards continued to deteriorate and died on 2 December 2015.
The medical cause of death was 1a. Multi Organ Failure, Sepsis 1b. Anastomotic Leak (Operated 1 December 2015), 1c. Ischaemic Terminal Ileum (operated 24/11/2015). II. Pulmonary Embolism (warfarinised), Rheumatoid Arthritis (on Methotrexate), Laparotomy for Ischaemic Small Bowel secondary to small bowel volvulus (operated 17/06/2015), Amyloidosis.

(1) During the Inquest it became clear that there is no reliable system or protocol for the dissemination of histology results to the named consultant for a patient. In this case the consultant for Mr Edwards informed the inquest that the histology result had gone to the file of Mr Edwards as he had been discharged. He did not chase the result as the operation passed without incident. The Consultant informed the court that had he had the result of histology showing amyloidosis that he would immediately have referred the patient on for urgent investigation of this serious condition. Having had these results at an early stage would have informed the treatment for Mr Edwards subsequently. The fact that this information was not passed in a timely fashion did not cause or contribute to the death of Mr Edwards. However, it is clear that unless there is a clear system for bringing histology results to the attention of a named Consultant that there could be a death in future. The consultant himself identified a need for a more robust system of delivering histology reports to consultants.