Alan Tear · Prevention of Future Deaths report

On 6 October 2015 I commenced an investigation into the death of Alan Tear.

I returned the following narrative conclusion:

Alan Tear died on the 1st May 2015, in Leicester General Hospital from post-procedure complications following the insertion of a biliary drain. At the time he was not being observed often and in accordance with his needs and opportunities to recognise and intervene were lost. It cannot be said whether any earlier intervention would on the balance of probabilities have altered the outcome.

Cause of death
1a Intraperitoneal haemorrhage
1b Biliary drain insertion for obstructive jaundice
1c Cholangiocarcinoma
2 Ischaemic heart disease, hypertension, diabetes mellitus

Mr Tear was receiving palliative treatment for cholangiocarcinoma. He underwent a drain insertion on 30th April 2015 by the interventional radiology team and appeared to cope well with this. It was recognised pre-operatively that there was a high risk of procedural complications and a 10% risk of mortality. He had appropriate observations in recovery and was then returned to the ward with post-operative instructions for regular observations. Most of these observations were not carried out. One set of observations that should have raised concerns did not result in any action.
Mr Tear died 11 hours post-operatively from a bleed caused by the drain that had become misplaced and caused a perforation of the peritoneum.

1. Post-operative instructions were not followed by the nursing staff.

2. Post-operative observations were not reported to medical staff as required when the EWS was rising.

3. It was not clear that the Intervention Radiology team knew or understood what observations the nursing staff would carry out and the communication between the teams needs to be reconsidered.