Gladys Margaret Borgogno · Prevention of Future Deaths report

On 3rd may 2018 an investigation into the death of Gladys Margaret Borgogno was commenced.
The investigation concluded at the end of the inquest on 29th July 2019. The conclusion of the inquest was that the deceased died due to a recognised complication of a surgical procedure.
The cause of death was:
1a Acute pancreatitis.
1b Gallstones and endoscopic retrograde cholangiopancreatography (ERCP).
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II Hypertensive heart disease.

1 )On the 24th April 2018, Mrs Borgogno underwent an ERCP procedure due to symptomatic bile duct stones. The procedure was uneventful but some stones remained.
2 ) Mrs Borgogno’s post procedure observations were normal but prior to discharge, she was noted to vomit bile. This was not regarded as being indicative of a diagnosis of pancreatitis following a medical review as there were no other clinical symptoms.
3) Mrs Borgogno was discharged home after the standard four hour post procedure hospital observations and provided with written discharge instructions which warned of seeking further medical advice if severe symptoms developed which included vomiting.
4) Mrs Borgogno continued to vomit in the car on the way home and at home, but did not seek further medical attention.
5) Mrs Borgogno was found the following morning lifeless on her living room floor with vomit in close proximity and was confirmed dead by paramedics at 10am on the 25th April 2018.

(1) The length of the post procedure observation period where there has been an episode of vomiting in the absence of any other symptoms and normal observations.
(2) The pre and post procedure written documentation in respect of the advice to seek further medical attention if vomiting developed post procedure upon discharge from hospital. In evidence at inquest, the treating Consultant Pancreatico-biliary Surgeon advised that he understood the family’s confusion surrounding the symptom of vomiting given the fact that Mrs Borgogno had vomited after the procedure but had been discharged from hospital. He advised that he would recommend that the hospital review its pre and post procedure ERCP documentation provided to patients.