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Investigation and inquest
On 14th October 2020 I commenced an investigation into the death of Norma Rushworth. The investigation concluded on the 13th May 2021 and the conclusion was one of Narrative: Died from complications of emergency surgery following a previous surgical procedure that had resulted in an abdominal dehiscence due in part to a wound infection not identified prior to the abdominal dehiscence.
The medical cause of death was 1a Bronchopneumonia 1b Immobilisation following surgery for Diverticulitis 1c Ischaemic Heart Disease, Aortic Valve Disease, Hypertensive disease
Circumstances of the death
Norma Rushworth was identified to have a narrowing of the sigmoid due to diverticulitis. She was operated on at Tameside General Hospital initially laparoscopically but this approach was not viable through open surgery. The colon was resectioned. She was discharged home. Whilst at home she had an abdominal dehiscence and was admitted back to Tameside General Hospital where she was operated on as an emergency. The dehiscence had occurred as a result of an unidentified infection of the wound, her age and cardio vascular compromise. She developed a chest infection. She had a cardiac arrest when the central line was removed. She was resuscitated and transferred back to the Intensive Care Unit. She continued to deteriorate. On 10th October 2020 she died at Tameside General Hospital. Post mortem examination found she had died from bronchopneumonia with significant underlying heart disease contributing to her death.
Coroner’s concerns
1. The inquest heard that due to the pandemic and restrictions Mrs Rushworth was not supported as she would usually have been at outpatient appointments. The inquest heard that this impacted significantly on the quality of the history available to clinicians; support for a vulnerable patient and her decision making.
2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage.
Information checked against the published report and official responses