William DOLEMAN and 3 others · Prevention of Future Deaths report

I commenced investigations into the deaths of William DOLEMAN, Anita BURKEY, Peter SELLARS and Carol Christine COLE. The investigation concluded at the end of the inquests, heard together, between 15 November 2021 and 17 December 2021. The conclusion of the inquests were as follows:

“Bill died on 1 April 2020, at the Queens Medical Centre, Nottingham, as a result of medical complications following an ERCP procedure performed on 19 March 2020, in which he suffered a recognised complication, namely a perforation to his duodenum, likely caused as a result of catheter trauma.
At the time, the procedure was not clinically indicated, and ought not to have gone ahead. If the procedure had been postponed for further imaging, Bill would not likely have died when he did and in the manner that he did.
Failures in his pre-procedure care directly contributed to his death.
There were missed opportunities to have diagnosed and treated Bill’s perforation during the procedure, and while this would likely have reduced his risk of dying, it might not have prevented his death.”

“Anita died on 5 April 2020, at the City Hospital, Nottingham, as a result of medical complications following an ERCP, performed on 19 March 2020, in which she suffered an iatrogenic perforation to her oesophagus. The procedure should never have been performed on this date and in the circumstances as it was unsafe to do so when Anita’s capacity and consent had not been appropriately assessed, and her history of dysphagia had not been explored.
Anita died as a direct result of the procedure which was performed as a result of significant failings in her care.”

“Peter died on 8 November 2020, at the Queens Medical Centre, Nottingham, from multi-organ failure caused by necrotising pancreatitis, which occurred as result of an ERCP procedure performed on 4 September 2020. Pancreatitis is a recognised complication of this procedure, which was necessary in order to treat Peter’s symptomatic choledocholithiasis.”

“Carol died on 11 September 2020, at the Queens Medical Centre, Nottingham, as a result of acute haemorrhagic pancreatitis, that was induced by an ERCP performed to treat choledocholithiasis, on 10 September 2020. Carol was at an elevated risk of developing this complication based on patient and procedure risk factors.”

All four patients died from endoscopic retrograde cholangio-pancreatography related complications, within a 6-month period, caused by the same doctor, during his training for this high-risk procedure.

1. A lack of robust patient pathway to ensure that all patient factors relevant to the clinical indication for, and safety of, ERCP are identified in advance of the procedure and discussed with the patient.
2. A lack of robust system for the recording of vetting of the procedure, capturing what information has been considered as part of this process.
3. Consent is not personalised, contrary to recommendations made by the ESGE in December 2019.
4. A lack of accountability between professionals for ensuring robust vetting and consent.