Gemma Suzanne Marshall · Prevention of Future Deaths report

On 27.03.24 I commenced an investigation into the death of «Gemma Suzanne Marshall (Female) (DoB 27.07.22) aged 46. Ms Marshall died on 15.03.24 at Huddersfield Royal Infirmary. The investigation concluded at the end of the inquest on 18.12.24. The conclusion of the inquest was in narrative form:

Gemma Marshall died on 15.03.24 at the Huddersfield Royal Infirmary from the consequences of her gastric band slipping and causing her stomach to twist and suffer a haemorrhagic infarction. The infarction caused a build-up of blood-stained fluid in her peritoneum which stimulated her vagus nerve which then caused an arrhythmia in her heart. She then collapsed in her school and could not be resuscitated. An outsourced CT scan failed to advise that the gastric band had slipped and this contributed to a failure to refer Gemma to bariatric specialists who could have intervened such that she might have lived. This failure represents neglect in the care that Gemma received.

Ms Marshall had private surgery for the fitting of a gastric band on 17.11.20. On 13.03.24 she attended the hospital with black vomiting and lower abdominal pain. She collapsed in the shower in hospital on 15.03.24 and did not recover. A postmortem found that the gastric band had “slipped” and that this was a causative factor in her death.

Evidence was given by the consultant surgeon who fitted the band, a senior bariatric surgeon at the treating hospital and a consultant radiologist at the treating hospital that the gastric band had slipped.

A CT scan was undertaken on 13.03.24 and reported on by a radiologist with expertise in musculoskeletal imaging (rather than gastric or abdominal imaging) who worked for an outsourced company. This was because of staff shortages in the hospital. The scan report mentioned the existence of the band but didn’t comment on the fact that the images clearly showed the band was out of position. That is that the stomach had slipped and had formed a pouch above the band.

This was, in my view, a critical failure in the care Ms Marshall received. Had this image been correctly reported, then a referral to bariatric surgeons would have probably been made which might have meant she would have survived.

Evidence from the consultant radiologist and the consultant surgeon in the hospital was that this failure to report that the band had slipped was because of a lack of familiarity in radiologists as to how slipped bands present, something which was compounded by 1. The increasing rarity of the procedure, 2. The consequences of specialists which are not familiar with the abdomen or bariatric issues and 3. A need to sometimes rely on outsourced third-party radiologists without the relevant specialist because of staff shortage.

While the hospital had taken steps to address this knowledge gap, there remained a concern that this lack of knowledge as to how slipped bands present was an issue of concern across the country and that other patients could face similar failures to Marshall.