Peter CARROLL · Prevention of Future Deaths report

I concluded the inquest into the death of Peter CARROLL on 5th October 2018 and recorded that he/she died from:

1a Peritonitis
b Perforated caecal volvulus; operated on
c Perianal squamous cell carcinoma requiring colostomy
II Coronary artery atheroma and pulmonary embolism and obesity

The deceased had a complex medical history. He had a chronic ulcer on the need to craft for over 30 years and this developed into malignancy diagnosed in early 2017.

A biopsy was taken on 6th October 2016. This was not recorded on the deceased discharge notification form and it was not until the 20th April 2017, at the result of squamous cell carcinoma, was it seen by the treating consultant.

Although the delayed biopsy reporting did not contribute to this death, if such delay continues, It could result in future fatalities.

An Incident Investigation Report Level 2 Comprehensive was compiled and the investigation reviewed the following:

1. The biopsy taken on 6th October 2016 was not recorded on the deceased’s discharge notes. Therefore, the treating consultant and administrative staff were unaware of the need to chase results or indeed the seriousness of the results.

2. The sample was wrongly labelled and as a result not reported to the multidisciplinary team warranting earlier action.

Although certain measures have been implemented to try to prevent recurrence, I am not satisfied that this is sufficient.

I am concerned that there is no leading physician signing off these reports in addition to processing by input on it systems thus reducing the effectiveness of the reporting.

I am concerned that a 6 month delay in reporting, on the evidence, meant that a curable treatment was not an option however if reported in a timely manner, would most likely have resulted in a favourable outcome.