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Investigation and inquest
On the 20 May 2019, I commenced an investigation into the death of Ms Jennifer McKoy. The investigation concluded at the end of the inquest on 19 February 2020. The conclusion of the inquest was a short narrative conclusion of:
Jennifer McKoy died after developing a recognised complication of Pulmonary embolism after a delayed diagnosis of adenocarcinoma of the gallbladder.
The cause of death was:
1a Pulmonary Venous Thrombo-embolism
1b Deep Phlebo-Thrombosis
1c Disseminated Adenocarcinoma of Gallbladder(operated)
Circumstances of the death
i) The deceased was a 58-year-old female patient who initially attended Walsall Manor Hospital for a laparoscopic cholecystectomy on 14 August 2018. Prior to this she was referred by her GP in March 2018 for pain in her right side. A subsequent ultrasound at hospital confirmed she had a thick-walled gall bladder with multiple gall stones.
ii) The surgical procedure was described as difficult due to a very thick-walled gallbladder packed full of stones and she was discharged home the following day. The gall bladder was sent for histology and reported to show 'chronic cholecystitis'.
iii) She re-attended the emergency department at Manor Hospital on 14 February 2019 with pain and a growing mass at the port site, this was reviewed and felt to be a haematoma or scar tissue and the patient was discharged home with plans for follow up.
iv) She was then seen in the vascular clinic on 20 March 2019 and ultrasound completed of mass at port site which was suggestive of haematoma. A further MRI completed on 15 March 2019 identified adenocarcinoma of gallbladder bed, abdominal wall, multiple hepatic and peritoneal and bony metastases with some ascites.
v) A retrospective review of the histology from 2018 showed that these slides demonstrated a carcinoma at that time which had not been identified.
vi) The patient was referred to oncology for palliative chemotherapy and sadly died on 17 May 2019.
Coroner’s concerns
1. Evidence emerged during the inquest that there was an inadequate audit process in place for monitoring non-suspicious samples by way of dip-sampling.
2. There was limited evidence of any protocol or policy in place for managing the anticoagulation/prophylaxis regime for community patients who have identifiable risk factors for developing complications.
Information checked against the published report and official responses