Diana Ruth Hughes · Prevention of Future Deaths report

On the 15/01/2014 I commenced an investigation into the death of Diana Ruth Hughes. The inquest was conducted on the 6/05/2015. She died of septicaemia caused by a necrotising fasciitis which had developed following her cholecystectomy, and a narrative conclusion was given.

This 66 year old lady was admitted to hospital for an elective laparoscopic cholecystectomy on the 6 January 2014. She was diagnosed with acute cholecystitis and underwent surgery on the 8 January 2014. A single dose of prophylactic antibiotics was given prior to surgery. The surgery was converted to open surgery and took approximately 4 hours. Two days later, the surgeon requested that she be admitted to a surgical ward for a minimum of 48 hours. However, she remained postoperatively on the surgical ward for 5 days. She developed tachycardia from 12.30pm on the 9 January 2014. The nursing team attempted to contact the surgical team until the evening of the 9 January when her condition rapidly deteriorated. At 19.25 hours she was put out of the ward and returned to the theatre for emergency exploration by laparotomy which revealed widespread infection and infarction of the bowel. It is probable that the widespread bowel infarction and infection was caused by antibiotic treatment, as opposed to a single dose of prophylactic antibiotics. Mrs Hughes remained critically ill throughout the emergency laparotomy. She passed away in the recovery room at 21.55 hours

(1) How specific instructions for a surgical procedure are communicated to other medical personnel via the WHO / Surgical checklist.