Robert Wright · Prevention of Future Deaths report

A Coronial investigation was commenced on 29th March 2021 into the death of Robert Wright. The Investigation concluded at the end of the inquest which I conducted on 4th November 2021. The conclusion was that Mr Wright died as the result of natural causes. The medical cause of death was 1 (a) Necrotising cholecystitis; 1(b) Gallstones

These were recorded as :-

Robert Wright, aged 80, suffered gallstones, which were first diagnosed in 2017. On 14th May 2019 he successfully underwent the removal of a gallstone by ERCP, after which he was referred for consideration of cholecystectomy. Following discharge, he developed biliary sepsis and underwent OGD, which identified suspected haematoma to the stomach wall. He was reviewed in clinic by the Consultant Surgeon on 2nd July 2019, who was unaware of the referral for consideration of cholecystectomy. However, Mr Wright subsequently underwent CT and CTC investigation, which would been indicated in any event. On 26th July 2019 his condition deteriorated and he was taken to the Prince Charles Hospital where he died. Post mortem examination identified that this occurred as a result of necrotising cholecystitis caused by gallstones.

During the investigation it became clear that the Consultant Surgeon who reviewed Mr Wright on 2nd July 2019 following Biopsy, CT scan and multi-disciplinary discussion after OGD on 13th June 2019 was unaware that Mr Wright had been separately referred for surgical consideration of cholecystectomy following ERCP on 15th May 2019

I would like to make clear that I found that there was absolutely no criticism to be made of that surgeon with respect to his lack of awareness of this issue, and that in the case of Mr Wright I was satisfied that his treatment pathway would not have been altered in any event.

However, it is a matter of concern that the surgeon assessing Mr Wright on 2nd July 2021 was not made aware of the related referral, a matter which in other circumstances may give rise to a risk of death.

(1) While outpatient referrals from a GP would have been available to the surgeon via an IT system, his evidence was that referrals within the Hospital were made on paper

(2) Those paper referrals were routinely not placed on the patient’s notes until 2-3 days prior to the clinic, in this case many weeks after being made.

(3) In these circumstances there is clearly a risk that a clinician will not have available to them all of the relevant evidence regarding a patient’s referrals and condition

(4) A busy consultant clinician should not in any event be placed in the position of having to look back through paper records to find a referral for a related condition which he had no reason to expect had been made.