Sarah Nadine Louise GIBBS · Prevention of Future Deaths report

On 25/04/2019 I commenced an investigation into the death of Sarah Nadine Louise GIBBS aged 38. The investigation concluded at the end of the inquest on 26/10/2020. The medical cause of death was:
1a) Aspiration of Gastric Contents
1b) Vomiting
1c)
1d)
2 Acute Peritonitis Following Recent Insertion of PEG tube to Assist Nutrition (in patient with learning disabilities and epilepsy)

The conclusion of the inquest was: Sarah Gibbs died shortly after returning home following a medical procedure.

Sarah Gibbs had learning disabilities, lacked mental capacity and had difficulty feeding. She underwent a PEG operation on 16 April 2019. Sarah was discharged home on 17 April 2019. The result of an earlier blood test was not known and she was not seen by a Doctor immediately prior to discharge. Later that day, Sarah became unresponsive and emergency services were called. A defibrillator was not able to be accessed. Sarah was pronounced dead at the scene.

Concerns were raised during the inquest with regard to communication between teams, particularly to the staff on duty at night as to what information was handed over. Evidence was heard of an easy to use form of communication tool which enables information to be transferred accurately, especially at handover time, between nurses and clinicians, known as SBARD. This helps in reducing the likelihood of errors in communication information.

It was not known whether this tool is in use although it was “hoped” it is being used. This is some eighteen months following Miss Gibb’s death.