Glenys Pollitt · Prevention of Future Deaths report

On 20th February 2017 I commenced an investigation into the death of Glenys Pollitt. The investigation concluded on the 14th August 2017 and the conclusion was one of Narrative: Died as a result of a recognised complication of Boerhaave Syndrome following an operation to repair the oesophageal tear carried out after it had been identified.
The medical cause of death was 1a Multi-organ failure;1bBoerhaave syndrome;
II Atrial fibrillation

Glenys Pollitt was admitted to Stepping Hill Hospital on the 6th February 2017. She was examined and an x-ray taken at 23:50 on 6th February 2017. She was diagnosed with community acquired pneumonia. A surgical emphysema visible on the x-ray was not identified. She deteriorated. She was seen by a number of clinicians who reviewed her and the x-ray. The surgical emphysema was not identified. On 7th February 2017 at 12.30pm she was reviewed by a consultant who ordered a CT scan and requested critical care input. The scan showed extensive surgical emphysema and a diagnosis of an oesophageal rupture (Boerhaave Syndrome) was made. An emergency operation was carried out on 7th February 2017. She was moved to ICU following the operation. She deteriorated and died on the 16th February 2017 from multi-organ failure.

1. It was accepted during the evidence that the x ray should ideally be viewed on a high-resolution screen rather than an standard screen. This increased the likelihood of significant abnormalities being detected. There are a number of such high-resolution screens for viewing of x rays. The evidence indicated that there was differing practice across the hospital as to when such screens were used and by whom.
2. At the inquest, the evidence given was that the clinicians had seen what they expected to see on the x ray rather than seeing the whole picture shown on the x ray. It was unclear what ongoing programme was in place for reinforcing the lessons learnt from this case amongst clinicians;
3. The process for escalation to consultant level and critical care was unclear.