Investigation and inquest
On 05 October 2023 I commenced an investigation into the death of David Alfred CURRY aged 77. The investigation concluded at the end of the inquest on 19 July 2024.
The medical cause of death was:
1a) Multi Organ Failure
1b) Urosepsis
1c) Ureteroscopy, Laser Lithotripsy and Insertion of Stent 20.09.2023
1d) Ureteric stent insertion for urosepsis due to an obstructing ureteric stone 07.04.2023
2) Atrial Fibrillation, Diabetes Mellitus, Chronic Obstructive Pulmonary Disease
The conclusion of the inquest was:
Mr Curry died from recognised risks of an appropriate procedure
Circumstances of the death
Mr Curry was admitted to Norfolk and Norwich University Hospital on 7 April 2023 when a stone was identified in the left lower ureter and a ureteric stent was placed as an emergency. Mr Curry was referred for a ureteroscopy which was undertaken on 20 September 2023 at Spire Norwich Hospital. Following the procedure Mr Curry showed signs of infection and was transferred to Norfolk and Norwich University Hospital where his condition deteriorated and he died on 1 October 2023.
Coroner’s concerns
1. Mr Curry was treated for an infected obstructed left kidney and a left ureteric stent was placed as an emergency on 7 April 2023. Mr Curry's name was added to the NHS waiting list for Day case urgent left ureteroscopy and laser stone fragmentation.
2. Mr Curry required timely management; coded as Priority (P) 2. P2 is used to denote the ideal time frame for performing surgery and in the event of this procedure, P2 timescale typically means within 4 weeks.
3. Evidence was heard that the risk of post operative urinary infection and sepsis is increased by prolonged stent dwell time.
4. Due to a lack of theatre capacity, Mr Curry did not receive a date for the proposed procedure at the NHS Trust and some five months following the initial procedure he approached Spire Norwich Hospital on 5 September 2023. The procedure was carried out on 15 September 2023.
5. Following the procedure being carried out Mr Curry developed sepsis and died on 1 October 2023.